Provider Demographics
NPI:1124299136
Name:WAIANAE COAST COMMUNITY MENTAL HEALTH CENTER, INC.
Entity type:Organization
Organization Name:WAIANAE COAST COMMUNITY MENTAL HEALTH CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:POHAOKALANI
Authorized Official - Middle Name:
Authorized Official - Last Name:SONODA-BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ, LSW
Authorized Official - Phone:808-696-4211
Mailing Address - Street 1:86-226 FARRINGTON HWY
Mailing Address - Street 2:
Mailing Address - City:WAIANAE
Mailing Address - State:HI
Mailing Address - Zip Code:96792-3128
Mailing Address - Country:US
Mailing Address - Phone:808-696-4211
Mailing Address - Fax:808-696-5516
Practice Address - Street 1:86-226 FARRINGTON HWY
Practice Address - Street 2:
Practice Address - City:WAIANAE
Practice Address - State:HI
Practice Address - Zip Code:96792-3128
Practice Address - Country:US
Practice Address - Phone:808-696-4211
Practice Address - Fax:808-696-5516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2024-09-19
Deactivation Date:2020-10-13
Deactivation Code:
Reactivation Date:2024-08-29
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental IllnessGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI050319501Medicaid
HI503195Medicaid