Healthcare Provider Details

I. General information

NPI: 1053564526
Provider Name (Legal Business Name): COMMUNITY CLINIC OF MAUI INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 IPU AUMAKUA LN
LAHAINA HI
96761
US

IV. Provider business mailing address

1881 NANI STREET
WAILUKU HI
96793-1811
US

V. Phone/Fax

Practice location:
  • Phone: 808-667-7598
  • Fax: 808-667-7492
Mailing address:
  • Phone: 808-667-7598
  • Fax: 808-667-7492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BETTY JANE OTT
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 808-872-4018