=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770954265
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REVELYN DOMINGSIL JACINTO PRIMARY CAREGIVER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2015
-----------------------------------------------------
Last Update Date | 10/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 94-913 KAHUAILANI ST
-----------------------------------------------------
City | WAIPAHU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96797-3326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-671-2605
-----------------------------------------------------
Fax | 808-671-2603
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 94-913 KAHUAILANI ST
-----------------------------------------------------
City | WAIPAHU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96797-3326
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-671-2605
-----------------------------------------------------
Fax | 808-671-2603
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number | HI110118067
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------