Provider Demographics
NPI:1962885277
Name:WAILEA IMAGING CENTER
Entity type:Organization
Organization Name:WAILEA IMAGING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:BINH
Authorized Official - Middle Name:
Authorized Official - Last Name:TU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-677-7727
Mailing Address - Street 1:MSC 61262 PO BOX 1300
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96807-1300
Mailing Address - Country:US
Mailing Address - Phone:808-677-7727
Mailing Address - Fax:808-697-5488
Practice Address - Street 1:100 WAILEA IKE DR
Practice Address - Street 2:
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-9524
Practice Address - Country:US
Practice Address - Phone:808-677-7727
Practice Address - Fax:808-697-5488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-06
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIW84651925-01261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology