Provider Demographics
NPI:1841603958
Name:PETTY BASA
Entity Type:Organization
Organization Name:PETTY BASA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NA/PRIMARY CARE GIVER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PETTY
Authorized Official - Middle Name:CAJALNE
Authorized Official - Last Name:BASA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-678-8331
Mailing Address - Street 1:94-249 PAIWA ST
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-3481
Mailing Address - Country:US
Mailing Address - Phone:808-678-8331
Mailing Address - Fax:808-678-8331
Practice Address - Street 1:94-249 PAIWA ST
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-3481
Practice Address - Country:US
Practice Address - Phone:808-678-8331
Practice Address - Fax:808-678-8331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency