Provider Demographics
NPI:1528042561
Name:COMMUNITY CLINIC OF MAUI, INC.
Entity Type:Organization
Organization Name:COMMUNITY CLINIC OF MAUI, INC.
Other - Org Name:MALAMA I KE OLA HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-872-4018
Mailing Address - Street 1:1881 NANI STREET
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1811
Mailing Address - Country:US
Mailing Address - Phone:808-871-7772
Mailing Address - Fax:808-872-4029
Practice Address - Street 1:1881 NANI STREET
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793
Practice Address - Country:US
Practice Address - Phone:808-871-7772
Practice Address - Fax:808-872-4029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-02
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI071290-01Medicaid
HI071290-01Medicaid