Healthcare Provider Details

I. General information

NPI: 1215359989
Provider Name (Legal Business Name): FIVE MOUNTAINS HAWAII, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2014
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64-1035 MAMALAHO HWY STE F
KAMUELA HI
96743-8440
US

IV. Provider business mailing address

PO BOX 818
KAMUELA HI
96743-0818
US

V. Phone/Fax

Practice location:
  • Phone: 808-885-5900
  • Fax: 808-885-6900
Mailing address:
  • Phone: 808-885-5900
  • Fax: 808-885-6900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CLAREN KUULEI KEALOHA-BEAUDET
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: PSYD
Phone: 808-885-5900