Provider Demographics
NPI:1811687262
Name:COMMUNITY CLINIC OF MAUI, INC.
Entity type:Organization
Organization Name:COMMUNITY CLINIC OF MAUI, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:VAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-871-7772
Mailing Address - Street 1:1881 NANI ST
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1811
Mailing Address - Country:US
Mailing Address - Phone:808-871-7772
Mailing Address - Fax:
Practice Address - Street 1:250 E LIPOA ST
Practice Address - Street 2:
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-8125
Practice Address - Country:US
Practice Address - Phone:808-871-7772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY CLINIC OF MAUI, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health