Provider Demographics
NPI:1750832259
Name:MAKANA O KA OLA HEALTH AND WELLNESS CLINIC
Entity Type:Organization
Organization Name:MAKANA O KA OLA HEALTH AND WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:PRUSKY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN FNP
Authorized Official - Phone:360-560-3801
Mailing Address - Street 1:1935 MAIN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1784
Mailing Address - Country:US
Mailing Address - Phone:360-560-3801
Mailing Address - Fax:
Practice Address - Street 1:1935 MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1784
Practice Address - Country:US
Practice Address - Phone:360-560-3801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI119306444801261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care