Healthcare Provider Details

I. General information

NPI: 1023864733
Provider Name (Legal Business Name): KINOHI MANA NUI SUPPORT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2024
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 HOOHULU ST
PEARL CITY HI
96782-2916
US

IV. Provider business mailing address

1412 HOOHULU ST
PEARL CITY HI
96782-2916
US

V. Phone/Fax

Practice location:
  • Phone: 808-723-2738
  • Fax:
Mailing address:
  • Phone: 808-723-2738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: DEVERLYN BAQUIRING KANG
Title or Position: EXECUTIVE DIRECTOR/FOUNDER
Credential:
Phone: 808-723-2738