Provider Demographics
NPI:1093841835
Name:INDEPENDENT LIVING EQUIPMENT AND PACMED
Entity type:Organization
Organization Name:INDEPENDENT LIVING EQUIPMENT AND PACMED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:MATSUNAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-537-1671
Mailing Address - Street 1:80 SAND ISLAND ACCESS RD STE 238
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-4912
Mailing Address - Country:US
Mailing Address - Phone:808-537-1671
Mailing Address - Fax:808-537-1393
Practice Address - Street 1:80 SAND ISLAND ACCESS RD STE 238
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-4912
Practice Address - Country:US
Practice Address - Phone:808-537-1671
Practice Address - Fax:808-791-6990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2018-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI10575079332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI250062Medicaid
HIA210094OtherHMSA PROVIDER ID
HI250062Medicaid