Provider Demographics
NPI:1306361241
Name:KAHALA CLINIC INTENSIVE TREATMENT PROGRAM
Entity Type:Organization
Organization Name:KAHALA CLINIC INTENSIVE TREATMENT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:KEIFER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-888-5228
Mailing Address - Street 1:4211 WAIALAE AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-5312
Mailing Address - Country:US
Mailing Address - Phone:808-888-5228
Mailing Address - Fax:808-732-6433
Practice Address - Street 1:4211 WAIALAE AVE STE 208
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-5312
Practice Address - Country:US
Practice Address - Phone:808-888-5228
Practice Address - Fax:808-732-6433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIGE-090-260-8896-01261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health