Provider Demographics
NPI:1851307375
Name:FULL LIFE
Entity Type:Organization
Organization Name:FULL LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-322-9333
Mailing Address - Street 1:75-6082 ALII DR STE 8
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-2306
Mailing Address - Country:US
Mailing Address - Phone:808-322-9333
Mailing Address - Fax:808-322-9334
Practice Address - Street 1:75-6082 ALII DR STE 8
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-2306
Practice Address - Country:US
Practice Address - Phone:808-322-9333
Practice Address - Fax:808-322-9334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2021-02-10
Deactivation Date:2007-06-19
Deactivation Code:
Reactivation Date:2012-01-12
Provider Licenses
StateLicense IDTaxonomies
N/A251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI516990-01MedicaidMEDICAID PROVIDER ID