Provider Demographics
NPI:1134660582
Name:BIG ISLAND PSYCHIATRY LLC
Entity Type:Organization
Organization Name:BIG ISLAND PSYCHIATRY LLC
Other - Org Name:BIG ISLAND PSYCHIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHANNING
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:SLATE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-678-5715
Mailing Address - Street 1:PO BOX 23
Mailing Address - Street 2:
Mailing Address - City:PAHOA
Mailing Address - State:HI
Mailing Address - Zip Code:96778-0023
Mailing Address - Country:US
Mailing Address - Phone:253-678-5715
Mailing Address - Fax:
Practice Address - Street 1:65-1230 MAMALAHOA HWY
Practice Address - Street 2:STE D21
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-8318
Practice Address - Country:US
Practice Address - Phone:253-678-5715
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-18
Last Update Date:2017-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-18550261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health