Healthcare Provider Details

I. General information

NPI: 1477163236
Provider Name (Legal Business Name): PNW KUPUNA CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 S 4TH AVE
SEQUIM WA
98382-3719
US

IV. Provider business mailing address

203 S 4TH AVE
SEQUIM WA
98382-3719
US

V. Phone/Fax

Practice location:
  • Phone: 808-756-8876
  • Fax:
Mailing address:
  • Phone: 808-756-8876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ISAAC ADAM SCHMIDT
Title or Position: CHEIF OPERATION OFFICER
Credential:
Phone: 808-756-8876