Provider Demographics
NPI:1386779080
Name:STEVENS, LARRY E
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:E
Last Name:STEVENS
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:PO BOX 1641
Mailing Address - Street 2:
Mailing Address - City:PAHOA
Mailing Address - State:HI
Mailing Address - Zip Code:96778-1641
Mailing Address - Country:US
Mailing Address - Phone:808-965-8696
Mailing Address - Fax:808-933-0533
Practice Address - Street 1:1045 KILAUEA AVE
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-4201
Practice Address - Country:US
Practice Address - Phone:808-974-4320
Practice Address - Fax:808-933-0533
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI539372-15Medicaid