Provider Demographics
NPI:1487037206
Name:LIBERTY DIALYSIS HAWAII LLC
Entity Type:Organization
Organization Name:LIBERTY DIALYSIS HAWAII LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA-ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-856-2102
Mailing Address - Street 1:10 HOOHUI RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAHAINA
Mailing Address - State:HI
Mailing Address - Zip Code:96761-9257
Mailing Address - Country:US
Mailing Address - Phone:808-669-6628
Mailing Address - Fax:808-669-1272
Practice Address - Street 1:10 HOOHUI RD STE 100
Practice Address - Street 2:
Practice Address - City:LAHAINA
Practice Address - State:HI
Practice Address - Zip Code:96761-9257
Practice Address - Country:US
Practice Address - Phone:808-669-6628
Practice Address - Fax:808-669-1272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1060527261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment