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General NPI Number Information
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NPI Number | 1386944437
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Entity Type | Organization
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Legal Business Name | MARIA CARIDAD ILAR-REVILLA COMMUNITY HEALTH CLINIC LLC
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Dates
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Enumeration Date | 10/22/2010
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Last Update Date | 10/15/2012
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Provider Practice Location Address
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Address Line | 94-866 MOLOALO ST STE 1B
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City | WAIPAHU
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State | HI
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Zip | 96797-3354
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Country | US
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Telephone | 808-677-5832
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Fax | 808-671-9109
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Provider Business Mailing Address
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Address Line | 94-866 MOLOALO ST STE 1B
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City | WAIPAHU
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State | HI
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Zip | 96797-3354
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Country | US
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Telephone | 808-677-5832
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Fax | 808-671-9109
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Authorized Official
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Title or Position | OWNER
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Name | DR. MARIA CARIDAD ILAR-REVILLA
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Credential | M.D.
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Telephone | 808-677-5832
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 9394
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License Number State | HI
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