Healthcare Provider Details

I. General information

NPI: 1922375211
Provider Name (Legal Business Name): EREDULIN V JULIAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2011
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17-202 IPUAIWAHA ST
KEAAU HI
96749-8229
US

IV. Provider business mailing address

17-202 IPUAIWAHA ST.
KEAAU HI
96749
US

V. Phone/Fax

Practice location:
  • Phone: 808-966-5450
  • Fax: 808-966-5450
Mailing address:
  • Phone: 808-966-5450
  • Fax: 808-966-5450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number531819
License Number StateHI

VIII. Authorized Official

Name: MRS. EREDULIN V JULIAN
Title or Position: OWNER
Credential:
Phone: 808-966-5450