Provider Demographics
NPI:1114253853
Name:MARY JEAN B. URSUA
Entity Type:Organization
Organization Name:MARY JEAN B. URSUA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY JEAN
Authorized Official - Middle Name:BARBADO
Authorized Official - Last Name:URSUA
Authorized Official - Suffix:
Authorized Official - Credentials:CAREGIVER
Authorized Official - Phone:808-877-0351
Mailing Address - Street 1:383 W PAPA AVE
Mailing Address - Street 2:
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96732-2639
Mailing Address - Country:US
Mailing Address - Phone:808-877-0351
Mailing Address - Fax:808-877-0351
Practice Address - Street 1:383 W PAPA AVE
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-2639
Practice Address - Country:US
Practice Address - Phone:808-877-0351
Practice Address - Fax:808-877-0351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-01
Last Update Date:2009-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIW03609234-01311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI587785Medicaid
HIW03609234-01Medicaid