Provider Demographics
NPI:1336487107
Name:WAIKOLOA
Entity Type:Organization
Organization Name:WAIKOLOA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARMA
Authorized Official - Middle Name:J
Authorized Official - Last Name:NELSON-BILLINGS
Authorized Official - Suffix:
Authorized Official - Credentials:SOCIAL SERVICE WORKE
Authorized Official - Phone:801-824-1771
Mailing Address - Street 1:243 N 1000 W
Mailing Address - Street 2:
Mailing Address - City:WEST BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84087-1930
Mailing Address - Country:US
Mailing Address - Phone:801-824-1771
Mailing Address - Fax:
Practice Address - Street 1:905 W 4000 S
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-8538
Practice Address - Country:US
Practice Address - Phone:801-295-3171
Practice Address - Fax:801-295-5451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility