Healthcare Provider Details

I. General information

NPI: 1659531622
Provider Name (Legal Business Name): KAUAI COMMUNITY HEALTH ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 OKA ST 101-A
KILAUEA HI
96754-5308
US

IV. Provider business mailing address

2460 OKA ST 101-A
KILAUEA HI
96754-5308
US

V. Phone/Fax

Practice location:
  • Phone: 808-828-2882
  • Fax: 808-828-0119
Mailing address:
  • Phone: 808-828-2882
  • Fax: 808-828-0119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number11990
License Number StateHI

VIII. Authorized Official

Name: DR. STEVE M ROGOFF
Title or Position: PARTNER
Credential: MD
Phone: 808-828-2885