Provider Demographics
NPI:1992792733
Name:HALE KUPUNA HERITAGE HOME, LLC
Entity type:Organization
Organization Name:HALE KUPUNA HERITAGE HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:HATA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-247-0003
Mailing Address - Street 1:45-181 WAIKALUA RD
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-2765
Mailing Address - Country:US
Mailing Address - Phone:808-247-0003
Mailing Address - Fax:
Practice Address - Street 1:4297C OMAO RD
Practice Address - Street 2:
Practice Address - City:KOLOA
Practice Address - State:HI
Practice Address - Zip Code:96756-9624
Practice Address - Country:US
Practice Address - Phone:808-742-7591
Practice Address - Fax:808-742-6563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-05
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI61-N313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI521030-01Medicaid
HI521030-01Medicaid