Provider Demographics
NPI:1457356164
Name:LEEWARD RADIATION ONCOLOGY
Entity Type:Organization
Organization Name:LEEWARD RADIATION ONCOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RAE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAMEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-678-9000
Mailing Address - Street 1:91-2135 FORT WEAVER RD
Mailing Address - Street 2:STE B120
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-1929
Mailing Address - Country:US
Mailing Address - Phone:808-678-9000
Mailing Address - Fax:808-677-1040
Practice Address - Street 1:91-2135 FORT WEAVER RD
Practice Address - Street 2:STE B120
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-1929
Practice Address - Country:US
Practice Address - Phone:808-678-9000
Practice Address - Fax:808-677-1040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRT0002261QX0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, Radiation
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI24785101Medicaid
HIH0000WCCHVMedicare PIN