Provider Demographics
NPI:1871655191
Name:WILSON HEALTHCARE, INC DBA HAWAIIAN HOUSE
Entity Type:Organization
Organization Name:WILSON HEALTHCARE, INC DBA HAWAIIAN HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:F
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-429-2616
Mailing Address - Street 1:1027 CALLE JUCA DR
Mailing Address - Street 2:
Mailing Address - City:LA HABRA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:90631-8654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12440 224TH ST
Practice Address - Street 2:
Practice Address - City:HAWAIIAN GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90716-1718
Practice Address - Country:US
Practice Address - Phone:562-429-2616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities