Healthcare Provider Details

I. General information

NPI: 1871797381
Provider Name (Legal Business Name): MARIMED FOUNDATION FOR ISLAND HEALTH CARE TRAINING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45-021 LIKEKE PL
KANEOHE HI
96744-2426
US

IV. Provider business mailing address

45-021 LIKEKE PL
KANEOHE HI
96744-2426
US

V. Phone/Fax

Practice location:
  • Phone: 808-236-2288
  • Fax: 808-235-1074
Mailing address:
  • Phone: 808-236-2288
  • Fax: 808-235-1074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateHI

VIII. Authorized Official

Name: DR. MATTHEW ALAN CLAYBAUGH
Title or Position: PRESIDENT CEO
Credential: PH.D.
Phone: 808-236-2288