Healthcare Provider Details

I. General information

NPI: 1134660582
Provider Name (Legal Business Name): BIG ISLAND PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2017
Last Update Date: 03/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65-1230 MAMALAHOA HWY STE D21
KAMUELA HI
96743-8318
US

IV. Provider business mailing address

PO BOX 23
PAHOA HI
96778-0023
US

V. Phone/Fax

Practice location:
  • Phone: 253-678-5715
  • Fax:
Mailing address:
  • Phone: 253-678-5715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberMD-18550
License Number StateHI

VIII. Authorized Official

Name: DR. CHANNING SCOTT SLATE
Title or Position: OWNER
Credential: M.D.
Phone: 253-678-5715