Healthcare Provider Details

I. General information

NPI: 1386236966
Provider Name (Legal Business Name): THE OHANA RETREAT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2021
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73-4617 KALOKO HALIA PL
KAILUA KONA HI
96740-8666
US

IV. Provider business mailing address

75-5915 WALUA RD
KAILUA KONA HI
96740-1375
US

V. Phone/Fax

Practice location:
  • Phone: 808-746-9003
  • Fax:
Mailing address:
  • Phone: 877-664-2622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. ELLIOTT SMITH
Title or Position: CEO
Credential:
Phone: 877-664-2622