Healthcare Provider Details

I. General information

NPI: 1952724841
Provider Name (Legal Business Name): VICKY BAGAIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2014
Last Update Date: 01/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94-1381 HIAAI PL
WAIPAHU HI
96797-3809
US

IV. Provider business mailing address

94-1381 HIAAI PL
WAIPAHU HI
96797-3809
US

V. Phone/Fax

Practice location:
  • Phone: 808-671-7308
  • Fax:
Mailing address:
  • Phone: 808-671-7308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: