Healthcare Provider Details

I. General information

NPI: 1992792733
Provider Name (Legal Business Name): HALE KUPUNA HERITAGE HOME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4297C OMAO RD
KOLOA HI
96756-9624
US

IV. Provider business mailing address

45-181 WAIKALUA RD
KANEOHE HI
96744-2765
US

V. Phone/Fax

Practice location:
  • Phone: 808-742-7591
  • Fax: 808-742-6563
Mailing address:
  • Phone: 808-247-0003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number61-N
License Number StateHI

VIII. Authorized Official

Name: RANDALL HATA
Title or Position: CFO
Credential:
Phone: 808-247-0003