Healthcare Provider Details

I. General information

NPI: 1780466466
Provider Name (Legal Business Name): NOAH MILTON KUBALL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 10/18/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 KAPAA QUARRY PL #5002
KAILUA HI
96734-4645
US

IV. Provider business mailing address

905 KALANIANAOLE HWY
KAILUA HI
96734-4645
US

V. Phone/Fax

Practice location:
  • Phone: 808-247-2973
  • Fax:
Mailing address:
  • Phone: 808-247-2973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number23-304263
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: