Provider Demographics
NPI:1487102877
Name:KA WAI OLA MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:KA WAI OLA MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEILANI
Authorized Official - Middle Name:
Authorized Official - Last Name:KERR
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:808-796-0168
Mailing Address - Street 1:1695 AUWAE RD
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-6908
Mailing Address - Country:US
Mailing Address - Phone:808-796-0168
Mailing Address - Fax:
Practice Address - Street 1:16-590 OLD VOLCANO RD
Practice Address - Street 2:STE. A
Practice Address - City:KEAAU
Practice Address - State:HI
Practice Address - Zip Code:96749-8158
Practice Address - Country:US
Practice Address - Phone:808-796-0168
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN-1450261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI11105633OtherMEDICARE PTAN
HI00A0324531OtherHMSA PROVIDER