Provider Demographics
NPI:1962659540
Name:BOBBY BENSON CENTER
Entity Type:Organization
Organization Name:BOBBY BENSON CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:808-293-7555
Mailing Address - Street 1:56-660 KAMEHAMEHA HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:KAHUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96731
Mailing Address - Country:US
Mailing Address - Phone:808-293-7555
Mailing Address - Fax:808-293-7196
Practice Address - Street 1:56-660 KAMEHAMEHA HWY
Practice Address - Street 2:
Practice Address - City:KAHUKU
Practice Address - State:HI
Practice Address - Zip Code:96731-2210
Practice Address - Country:US
Practice Address - Phone:808-293-7555
Practice Address - Fax:808-293-7196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI320800000X320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness