=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467346916
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY CLINIC OF MAUI, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2025
-----------------------------------------------------
Last Update Date | 06/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 660 LONO AVE
-----------------------------------------------------
City | KAHULUI
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96732-2530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-727-4000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1881 NANI ST
-----------------------------------------------------
City | WAILUKU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96793-1811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-871-7772
-----------------------------------------------------
Fax | 808-872-4029
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JOHN R VAZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 808-871-7772
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS1000X
-----------------------------------------------------
Taxonomy Name | Student Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------