Provider Demographics
NPI:1023100229
Name:KUPUNA ALTERNATIVE CARE, LLC
Entity type:Organization
Organization Name:KUPUNA ALTERNATIVE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN CASE MANAGER, ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEA
Authorized Official - Middle Name:D
Authorized Official - Last Name:NORDLOH
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN
Authorized Official - Phone:808-933-9229
Mailing Address - Street 1:HC 2 BOX 6924
Mailing Address - Street 2:
Mailing Address - City:KEAAU
Mailing Address - State:HI
Mailing Address - Zip Code:96749-9336
Mailing Address - Country:US
Mailing Address - Phone:808-933-9229
Mailing Address - Fax:808-933-1444
Practice Address - Street 1:350 LEHUA ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2351
Practice Address - Country:US
Practice Address - Phone:808-933-9229
Practice Address - Fax:808-933-1444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI30137544251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI566961OtherMEDICAID PROVIDER NUMBER