Provider Demographics
NPI:1265969703
Name:DERMACARE HI LLC
Entity type:Organization
Organization Name:DERMACARE HI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEPKE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:808-855-8380
Mailing Address - Street 1:4520 KUKUI ST STE 101
Mailing Address - Street 2:
Mailing Address - City:KAPAA
Mailing Address - State:HI
Mailing Address - Zip Code:96746-1770
Mailing Address - Country:US
Mailing Address - Phone:808-855-8380
Mailing Address - Fax:855-635-8353
Practice Address - Street 1:4520 KUKUI ST STE 101
Practice Address - Street 2:
Practice Address - City:KAPAA
Practice Address - State:HI
Practice Address - Zip Code:96746-1770
Practice Address - Country:US
Practice Address - Phone:808-855-8380
Practice Address - Fax:855-635-8353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207N00000X
HI2012001836363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH110085Medicaid