Provider Demographics
NPI:1093190589
Name:DR LISA TAKETA
Entity type:Organization
Organization Name:DR LISA TAKETA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAKETA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-868-8068
Mailing Address - Street 1:4450 KULA HWY UNIT 264
Mailing Address - Street 2:
Mailing Address - City:KULA
Mailing Address - State:HI
Mailing Address - Zip Code:96790-3018
Mailing Address - Country:US
Mailing Address - Phone:808-868-8063
Mailing Address - Fax:
Practice Address - Street 1:7 AEWA PL
Practice Address - Street 2:
Practice Address - City:MAKAWAO
Practice Address - State:HI
Practice Address - Zip Code:96768-8882
Practice Address - Country:US
Practice Address - Phone:808-868-8063
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-25
Last Update Date:2015-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIACU-338305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service