Healthcare Provider Details

I. General information

NPI: 1619721263
Provider Name (Legal Business Name): COMMUNITY CLINIC OF MAUI, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2024
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 HOOHUI RD
LAHAINA HI
96761-9256
US

IV. Provider business mailing address

1881 NANI ST
WAILUKU HI
96793-1811
US

V. Phone/Fax

Practice location:
  • Phone: 808-871-7772
  • Fax: 808-872-4029
Mailing address:
  • Phone: 808-871-7772
  • Fax: 808-872-4029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN R VAZ
Title or Position: CEO
Credential:
Phone: 808-871-7772