Healthcare Provider Details

I. General information

NPI: 1780738005
Provider Name (Legal Business Name): WAIMANALO HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41-1347 KALANIANAOLE HWY
WAIMANALO HI
96795-1247
US

IV. Provider business mailing address

41-1347 KALANIANAOLE HWY
WAIMANALO HI
96795-1247
US

V. Phone/Fax

Practice location:
  • Phone: 808-954-7107
  • Fax: 808-259-6449
Mailing address:
  • Phone: 808-954-7107
  • Fax: 808-259-6449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberW20416724-01
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MS. MARY ONEHA
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: APRN, PHD, FAAN
Phone: 808-954-7107