Provider Demographics
NPI:1255336376
Name:ISLAND NURSING HOME, INC.
Entity type:Organization
Organization Name:ISLAND NURSING HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LELAND
Authorized Official - Middle Name:M
Authorized Official - Last Name:YAGI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-946-5027
Mailing Address - Street 1:1205 ALEXANDER ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96826-1229
Mailing Address - Country:US
Mailing Address - Phone:808-946-5027
Mailing Address - Fax:866-596-0130
Practice Address - Street 1:1205 ALEXANDER ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96826-1229
Practice Address - Country:US
Practice Address - Phone:808-946-5027
Practice Address - Fax:866-596-0130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2-N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI12-5005OtherKAISER
HI0848-2OtherHMSA
HI008403-01Medicaid
HI125005Medicare Oscar/Certification
HI008403-01Medicaid
HI1250230001Medicare NSC
HI12-5005Medicare PIN