Provider Demographics
NPI:1558770651
Name:ULTRACARE DIAGNOSTIC IMAGING, LLC
Entity Type:Organization
Organization Name:ULTRACARE DIAGNOSTIC IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:HAZELBAKER
Authorized Official - Suffix:
Authorized Official - Credentials:RDMS
Authorized Official - Phone:808-354-3510
Mailing Address - Street 1:122 ONEAWA ST STE 102
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-2524
Mailing Address - Country:US
Mailing Address - Phone:808-354-3510
Mailing Address - Fax:
Practice Address - Street 1:122 ONEAWA ST STE 102
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-2524
Practice Address - Country:US
Practice Address - Phone:808-354-3510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-04
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1619101Medicaid