Healthcare Provider Details

I. General information

NPI: 1962835165
Provider Name (Legal Business Name): ANTHONY LEE YATES CSAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2013
Last Update Date: 08/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16-759 WAO KELE ST.
KURTISTOWN HI
96760-0711
US

IV. Provider business mailing address

PO BOX 711
KURTISTOWN HI
96760-0711
US

V. Phone/Fax

Practice location:
  • Phone: 808-936-4382
  • Fax:
Mailing address:
  • Phone: 808-936-4382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1657-11
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: