=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881577138
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KAANAPALI BEACH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2025
-----------------------------------------------------
Last Update Date | 07/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 516 23RD AVE SE
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98372-4659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-845-6631
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 599 MENLO DR STE 200
-----------------------------------------------------
City | ROCKLIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95765-3725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | RYAN WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-945-1248
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------