Provider Demographics
NPI:1649687120
Name:FAMILY SUPPORT SERVICES OF WEST HAWAII
Entity type:Organization
Organization Name:FAMILY SUPPORT SERVICES OF WEST HAWAII
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-334-4115
Mailing Address - Street 1:75-127 LUNAPULE RD STE 11
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-2119
Mailing Address - Country:US
Mailing Address - Phone:808-334-4115
Mailing Address - Fax:808-326-4063
Practice Address - Street 1:75-127 LUNAPULE RD STE 11
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-2119
Practice Address - Country:US
Practice Address - Phone:808-334-4115
Practice Address - Fax:808-326-4063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI64642402Medicaid