Healthcare Provider Details

I. General information

NPI: 1265537302
Provider Name (Legal Business Name): LIBERTY DIALYSIS-HAWAII LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1831 WILI PA LOOP
WAILUKU HI
96793-1273
US

IV. Provider business mailing address

2226 LILIHA ST SUITE 226
HONOLULU HI
96817-1600
US

V. Phone/Fax

Practice location:
  • Phone: 808-242-6400
  • Fax: 808-244-5712
Mailing address:
  • Phone: 808-585-4600
  • Fax: 808-585-4601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. DENISE VANVALKENBURGH
Title or Position: VICE PRESIDENT CLINICAL OPERATIONS
Credential:
Phone: 478-798-8003