NPIMap

Organization Active NPI

Community Clinic of Maui, Inc.

  • Community Health Clinic/Center
  • Wailuku, HI
National Provider Identifier
1528042561
Registry record updated Nov 8, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Health Clinic/CenterTaxonomy code 261QC1500X
Legal business name
COMMUNITY CLINIC OF MAUI, INC.
Practice address
1881 Nani Street
Wailuku, HI 96793
Phone
(808) 872-4006
Fax
(808) 495-0026
NPI assigned
Dec 2, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 8, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
John VazNPI 1952556201
Title
Chief Executive Officer
Phone
(808) 872-4018

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Community Health Clinic/Center 261QC1500X Primary
Federally Qualified Health Center (FQHC) 261QF0400X
Multi-Specialty Clinic/Center 261QM1300X

Addresses

Primary practice location

1881 Nani Street
Wailuku, HI 96793

Mailing address

1881 Nani Street
Wailuku, HI 96793-1811
Phone (808) 871-7772

Other identifiers 1

IdentifierTypeStateIssuer
071290-01MedicaidHI

Other names 1

  • Malama I Ke Ola Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in HI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040219000740 HI Part B Supplier - Clinic/Group Practice 2466365440 Receives reassigned benefits from 32 practitioners
6 other NPIs on this enrollment
Practice locations: Lahaina, HI; Wailuku, HI; Kihei, HI; Kahului, HI
O20050505000217 HI Part A Provider - Federally Qualified Health Center (FQHC) 2466365440 Practice locations: Wailuku, HI

Federally qualified health center certification: CCN 121812

Legal name
COMMUNITY CLINIC OF MAUI INC
Doing business as
MALAMA I KE OLA HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 25, 2000
Last certification
Jul 25, 2000
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
1881 Nani St
Wailuku, HI 96793-1811

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 6

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Community Clinic of Mau8 organizations share this tax ID, including this one

Other organizations with this tax ID 7

Organizations that report the same tax identification number in the National Provider Directory.

Locations

660 Lono Ave
Kahului, HI 96732
Phone (808) 727-4000

10 Hoohui Rd
Ste 308
Lahaina, HI 96761
Phone (808) 758-3456

Ownership & related parties

All disclosed owners & managing parties 10

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Monique Van Der Aa Individual Corporate OfficerChief Financial Officer Aug 20, 2018
Nicole M.N. Galicinao Individual Corporate DirectorBoard Member/Consumer Oct 19, 2021
Vanessa Medeiros Individual Corporate Director Sep 24, 2010
Margaret Batangan Individual Corporate DirectorBoard Member - Director Nov 19, 2024
Lorrin Pang Individual Corporate Director Sep 24, 2010
Andrea Poling Individual Corporate DirectorBoard of Director/Consumer Apr 18, 2023
John Vaz Individual Corporate OfficerChief Executive Officer Jul 1, 2022
W-2 Managing EmployeeChief Executive Officer Jul 1, 2022
Operational/Managerial ControlChief Executive Officer Jul 1, 2022
Gerard F Livaudais Individual Corporate DirectorBoard Member Jul 18, 2023
Sharon M Lund Individual Corporate DirectorBoard Member Dec 3, 2018
Charles Keoho Individual Corporate Director Mar 1, 2014

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

  • John R Vaz, MD
    • Infectious Disease Physician
    • Wailuku, HI
    • NPI 1952556201

    Corporate Officer, Operational/Managerial Control, W-2 Managing Employee

    CMS ownership

Practitioners & affiliated clinicians

Practitioners 37

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 37

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1133481600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1731024000000",
    "number": "1528042561",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1881 NANI STREET",
            "city": "WAILUKU",
            "state": "HI",
            "postal_code": "967931811",
            "telephone_number": "808-871-7772",
            "fax_number": "808-872-4029"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1881 NANI STREET",
            "city": "WAILUKU",
            "state": "HI",
            "postal_code": "96793",
            "telephone_number": "808-872-4006",
            "fax_number": "808-495-0026"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY CLINIC OF MAUI, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-12-02",
        "last_updated": "2024-11-08",
        "certification_date": "2024-11-08",
        "status": "A",
        "authorized_official_last_name": "VAZ",
        "authorized_official_first_name": "JOHN",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "808-872-4018"
    },
    "taxonomies": [
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "071290-01",
            "state": "HI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Malama I Ke Ola Health Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Malama I Ke Ola Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Wailuku, HI

Sources for this page

Verify at the official NPI Registry.