Provider Demographics
NPI:1053790899
Name:THRIVE FOR LIFE LLC
Entity type:Organization
Organization Name:THRIVE FOR LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DAMIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SEMPIO
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:808-226-2440
Mailing Address - Street 1:45-1047 PAHUWAI PL
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-3311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:45-1047 PAHUWAI PL
Practice Address - Street 2:
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744-3311
Practice Address - Country:US
Practice Address - Phone:808-226-2440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOT-585171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI=========Medicaid