=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720774144
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MALAMA RECOVERY HI LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2023
-----------------------------------------------------
Last Update Date | 04/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 425 ENA RD PH 6B
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96815-1712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-781-3153
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 425 ENA RD PH 6B
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96815-1712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATIONS OFFICER
-----------------------------------------------------
Name | DONALD FUJIYAMA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 808-781-3153
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------