Provider Demographics
NPI:1710401666
Name:VALLEY ISLE SENIOR CARE
Entity Type:Organization
Organization Name:VALLEY ISLE SENIOR CARE
Other - Org Name:LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MILTON
Authorized Official - Middle Name:T
Authorized Official - Last Name:NASU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-227-8450
Mailing Address - Street 1:345 S LEHUA ST
Mailing Address - Street 2:
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96732-2641
Mailing Address - Country:US
Mailing Address - Phone:808-227-8450
Mailing Address - Fax:808-395-6019
Practice Address - Street 1:345 S LEHUA ST
Practice Address - Street 2:KAHULUI
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-9673
Practice Address - Country:US
Practice Address - Phone:808-227-8450
Practice Address - Fax:808-227-8450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-02
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GE077954048001OtherGE LICENSE