Provider Demographics
NPI:1841427739
Name:KOKUA VILLA, INC.
Entity Type:Organization
Organization Name:KOKUA VILLA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSALINE
Authorized Official - Middle Name:G
Authorized Official - Last Name:WHITLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-696-7000
Mailing Address - Street 1:86-080 FARRINGTON HWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WAIANAE
Mailing Address - State:HI
Mailing Address - Zip Code:96792-3069
Mailing Address - Country:US
Mailing Address - Phone:808-696-7000
Mailing Address - Fax:808-696-7003
Practice Address - Street 1:86-080 FARRINGTON HWY
Practice Address - Street 2:SUITE 102
Practice Address - City:WAIANAE
Practice Address - State:HI
Practice Address - Zip Code:96792-3069
Practice Address - Country:US
Practice Address - Phone:808-696-7000
Practice Address - Fax:808-696-7003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI251C00000X, 251S00000X, 261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI516908Medicaid