Provider Demographics
NPI:1720335318
Name:FAMILY SUPPORT SERVICES OF WESTHAWAII
Entity Type:Organization
Organization Name:FAMILY SUPPORT SERVICES OF WESTHAWAII
Other - Org Name:KONA CHILD DEVELOPMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:PAYL
Authorized Official - Last Name:WOFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:LSW
Authorized Official - Phone:808-334-4189
Mailing Address - Street 1:75-127 LUNAPULE RD
Mailing Address - Street 2:SUITE 11
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-2119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75-127 LUNAPULE RD
Practice Address - Street 2:SUITE 11
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-2119
Practice Address - Country:US
Practice Address - Phone:808-334-4116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-14
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI64642402Medicaid