| Organization Name: | KOOLAULOA COMMUNITY HEALTH AND WELLNESS CENTER, INC. |
| NPI Number: | 1063833655 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | BENJAMIN F PETTUS (CHIEF EXECUTIVE OFFICER) |
| Mailing Address: | 54-316 Kamehameha Hwy Hauula |
| State: | HI US |
| Postal Code: | 967179539 |
| Phone Number: | 8082939216 |
| Fax Number: | |
| NPI Enumeration Date: | 12/27/2013 |
| NPI Last Update Date: | 12/27/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QF0400X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | HI |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Federally Qualified Health Center (FQHC) |
| Taxonomy Definition: | |