Provider Demographics
NPI:1982123956
Name:AGUSTIN, DARYLLE DAVE REBANO
Entity Type:Individual
Prefix:
First Name:DARYLLE DAVE
Middle Name:REBANO
Last Name:AGUSTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 NOELANI ST
Mailing Address - Street 2:
Mailing Address - City:PEARL CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96782-2932
Mailing Address - Country:US
Mailing Address - Phone:808-724-1338
Mailing Address - Fax:808-200-5211
Practice Address - Street 1:1108 NOELANI ST
Practice Address - Street 2:
Practice Address - City:PEARL CITY
Practice Address - State:HI
Practice Address - Zip Code:96782-2932
Practice Address - Country:US
Practice Address - Phone:808-724-1338
Practice Address - Fax:808-200-5211
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1170030376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1170030Medicaid