MEDICARE: CULTIVATE MENTAL HEALTH & WELLNESS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1336993971
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CULTIVATE MENTAL HEALTH & WELLNESS, LLC

Provider Business Mailing Address
First Line	:	76-6225 KUAKINI HWY STE C101
Second Line	:
City	:	KAILUA KONA
State	:	HI
Zip	:	96740-3212
Country	:	US
Telephone Number	:	808-329-7067
Fax Number	:	808-329-2404

Provider Business Practice Location Address
First Line	:	76-6225 KUAKINI HWY STE C101
Second Line	:
City	:	KAILUA KONA
State	:	HI
Zip	:	96740-3212
Country	:	US
Telephone Number	:	808-329-7067
Fax Number	:	808-329-2404

Authorized Official
Title or Position	:	OWNER
Name	:	DR. VIRGINIA BURFORD HATCH-PIGOTT
Credential	:	MD
Telephone Number	:	808-854-7028

Provider Enumeration Date	:	04/11/2024
Last Update Date	:	04/11/2024

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