Provider Demographics
NPI:1679754097
Name:LANAI COMMUNITY HEALTH CENTER
Entity type:Organization
Organization Name:LANAI COMMUNITY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-565-6919
Mailing Address - Street 1:PO BOX 630142
Mailing Address - Street 2:
Mailing Address - City:LANAI CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96763-0142
Mailing Address - Country:US
Mailing Address - Phone:808-565-6919
Mailing Address - Fax:
Practice Address - Street 1:333 SIXTH ST
Practice Address - Street 2:
Practice Address - City:LANAI CITY
Practice Address - State:HI
Practice Address - Zip Code:96763
Practice Address - Country:US
Practice Address - Phone:808-565-6919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI509596Medicaid
HI121854Medicaid