Healthcare Provider Details

I. General information

NPI: 1740454594
Provider Name (Legal Business Name): MARIMED FOUNDATION FOR ISLAND HEALTH CARE TRAINING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 04/14/2008
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: 808-247-4032
Mailing address:
  • Phone: 808-236-2288
  • Fax: 808-247-4032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License NumberW20365520-01
License Number StateHI

VIII. Authorized Official

Name: LEONA LOO
Title or Position: HUMAN RESOURCES MANAGER
Credential:
Phone: 808-236-2288