Provider Demographics
NPI:1558765719
Name:MAUI CANCER CLINIC, INC.
Entity Type:Organization
Organization Name:MAUI CANCER CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALTAHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-280-4858
Mailing Address - Street 1:24 NORTH CHURCH STREET SUITE 308
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793
Mailing Address - Country:US
Mailing Address - Phone:808-242-1110
Mailing Address - Fax:855-839-9759
Practice Address - Street 1:24 NORTH CHURCH STREET SUITE 308
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793
Practice Address - Country:US
Practice Address - Phone:808-242-1110
Practice Address - Fax:855-839-9759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-17
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI68766801Medicaid
WVI06456Medicare UPIN
HI68766801Medicaid