Provider Demographics
NPI:1164662904
Name:STATE OF HAWAII DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:STATE OF HAWAII DEPARTMENT OF HEALTH
Other - Org Name:CAMHD - HERITAGE YOUTH SVC/ BIRDSEYE RTC
Other - Org Type:Other Name
Authorized Official - Title/Position:CAMHD ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STANTON
Authorized Official - Middle Name:M
Authorized Official - Last Name:MICHELS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-733-9339
Mailing Address - Street 1:3627 KILAUEA AVE
Mailing Address - Street 2:RM 101
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-2317
Mailing Address - Country:US
Mailing Address - Phone:808-733-9333
Mailing Address - Fax:808-733-9357
Practice Address - Street 1:3627 KILAUEA AVE
Practice Address - Street 2:RM 101
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-2317
Practice Address - Country:US
Practice Address - Phone:808-733-9333
Practice Address - Fax:808-733-9357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-05
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health