Provider Demographics
NPI:1689896953
Name:KOKUA KALIHI VALLEY COMPREHENSIVE FAMILY SERVICES
Entity Type:Organization
Organization Name:KOKUA KALIHI VALLEY COMPREHENSIVE FAMILY SERVICES
Other - Org Name:GULICK ELDER CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DERAUF
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:808-791-9400
Mailing Address - Street 1:2239 NORTH SCHOOL STREET
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819
Mailing Address - Country:US
Mailing Address - Phone:808-791-9400
Mailing Address - Fax:808-848-0979
Practice Address - Street 1:1846 GULICK AVENUE
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819
Practice Address - Country:US
Practice Address - Phone:808-848-0977
Practice Address - Fax:808-848-8689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI261QH100X261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI121838OtherMEDICARE ID
HI00992101Medicaid
HIHKKVHMedicare UPIN