Provider Demographics
NPI:1013350099
Name:GERALD J MCKENNA M.D. INC DBA MCKENNA RECOVERY CENTER
Entity Type:Organization
Organization Name:GERALD J MCKENNA M.D. INC DBA MCKENNA RECOVERY CENTER
Other - Org Name:KE ALA PONO RECOVERY CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MCKENNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-246-0663
Mailing Address - Street 1:4374 KUKUI GROVE ST
Mailing Address - Street 2:STE 104
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-2007
Mailing Address - Country:US
Mailing Address - Phone:808-246-0663
Mailing Address - Fax:808-246-1806
Practice Address - Street 1:4374 KUKUI GROVE ST
Practice Address - Street 2:STE 104
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-2007
Practice Address - Country:US
Practice Address - Phone:808-246-0663
Practice Address - Fax:808-246-1806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-09
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD60412084A0401X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI02661901Medicaid
HI02661901Medicaid