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General NPI Number Information
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NPI Number | 1306904461
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Entity Type | Organization
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Legal Business Name | BOBBY BENSON CENTER
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Dates
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Enumeration Date | 12/04/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 56-660 KAMEHAMEHA HWY
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City | KAHUKU
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State | HI
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Zip | 96731-2210
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Country | US
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Telephone | 808-293-7555
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Fax | 808-293-7196
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Provider Business Mailing Address
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Address Line | 56-660 KAMEHAMEHA HWY
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City | KAHUKU
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State | HI
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Zip | 96731-2210
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Country | US
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Telephone | 808-293-7555
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Fax | 808-293-7196
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. JEFFRIE WAGNER
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Credential |
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Telephone | 808-293-7555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3245S0500X
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Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
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License Number | 53-STF
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License Number State | HI
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