Healthcare Provider Details

I. General information

NPI: 1518225531
Provider Name (Legal Business Name): SMALL KINE POLYNESIAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 04/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55-025 LANIHULI ST
LAIE HI
96762-1225
US

IV. Provider business mailing address

55-025 LANIHULI ST
LAIE HI
96762-1225
US

V. Phone/Fax

Practice location:
  • Phone: 808-457-9897
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateHI

VIII. Authorized Official

Name: JOE WILSON
Title or Position: SOCIAL WORKER
Credential:
Phone: 808-457-9897