Provider Demographics
NPI:1053666842
Name:KAHALA CLINIC LLC
Entity Type:Organization
Organization Name:KAHALA CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:KEIFER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-542-7349
Mailing Address - Street 1:4211 WAIALAE AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-5319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4211 WAIALAE AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-5319
Practice Address - Country:US
Practice Address - Phone:808-542-7349
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD129872084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty