Provider Demographics
NPI:1154680585
Name:KAPIOLANI MEDICAL CENTER EARLY INTERVENTION PROGRAM
Entity Type:Organization
Organization Name:KAPIOLANI MEDICAL CENTER EARLY INTERVENTION PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARK
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:808-483-4912
Mailing Address - Street 1:99-080 KAUHALE ST
Mailing Address - Street 2:
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-4116
Mailing Address - Country:US
Mailing Address - Phone:808-483-4906
Mailing Address - Fax:
Practice Address - Street 1:99-080 KAUHALE ST
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-4116
Practice Address - Country:US
Practice Address - Phone:808-483-4906
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-04
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI64710901Medicaid