Provider Demographics
NPI:1073710976
Name:HALE KOKUA, INC.
Entity Type:Organization
Organization Name:HALE KOKUA, INC.
Other - Org Name:SOUTH GRANT ICF / DDH
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:PUREZA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GANIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-520-5545
Mailing Address - Street 1:1433 DAKOTA AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401
Mailing Address - Country:US
Mailing Address - Phone:650-685-4779
Mailing Address - Fax:650-627-4357
Practice Address - Street 1:1618 S GRANT ST
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2657
Practice Address - Country:US
Practice Address - Phone:650-578-1183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220000232320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC60789HOtherPROVIDER NUMBER