Organization
FULL LIFE
Active
Organization
FULL LIFE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JIM KILGORE (EXECUTIVE DIRECTOR)
(808) 322-9333
Entity
Organization
Contact information
Practice address
75-6082 ALII DR STE 8, KAILUA KONA, HI 96740-2306
(808) 322-9333
(808) 322-9334
Mailing address
75-6082 ALII DR STE 8, KAILUA KONA, HI 96740-2306
(808) 322-9333
(808) 322-9334
Taxonomy
Speciality
Code
Description
License number
State
251C00000X
Developmentally Disabled Services Day Training Agency
Primary
N/A
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
516990-01
MEDICAID PROVIDER ID
HI
Enumeration date
08/01/2006
Last updated
02/10/2021
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