Provider Demographics
NPI:1689814055
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:808-873-6305
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:808-873-6305
Practice Address - Fax:808-872-4029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-25
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center