Healthcare Provider Details

I. General information

NPI: 1932140811
Provider Name (Legal Business Name): LIBERTY DIALYSIS - HAWAII LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MAUI LANI PKWY
WAILUKU HI
96793-2443
US

IV. Provider business mailing address

105 MAUI LANI PKWY
WAILUKU HI
96793-2443
US

V. Phone/Fax

Practice location:
  • Phone: 808-244-9600
  • Fax: 808-244-5712
Mailing address:
  • Phone: 808-244-9600
  • Fax: 808-244-5712

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: BARRY L. BLANTON
Title or Position: VICE PRESIDENT
Credential:
Phone: 781-699-9000