Provider Demographics
NPI:1821367723
Name:LEEWARD EARLY CHILDHOOD SERVICES PROGRAM
Entity Type:Organization
Organization Name:LEEWARD EARLY CHILDHOOD SERVICES PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MAE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRACEROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-453-6960
Mailing Address - Street 1:860 FOURTH ST
Mailing Address - Street 2:ROOM #150
Mailing Address - City:PEARL CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96782-3312
Mailing Address - Country:US
Mailing Address - Phone:808-453-6960
Mailing Address - Fax:808-453-6964
Practice Address - Street 1:860 FOURTH ST
Practice Address - Street 2:ROOM #150
Practice Address - City:PEARL CITY
Practice Address - State:HI
Practice Address - Zip Code:96782-3312
Practice Address - Country:US
Practice Address - Phone:808-453-6960
Practice Address - Fax:808-453-6964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI64626802Medicaid