Provider Demographics
NPI:1861168593
Name:BALISACAN, MAWICELICA M
Entity type:Individual
Prefix:
First Name:MAWICELICA
Middle Name:M
Last Name:BALISACAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-941 KUHAULUA ST
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-2844
Mailing Address - Country:US
Mailing Address - Phone:808-304-3590
Mailing Address - Fax:808-379-0468
Practice Address - Street 1:94-941 KUHAULUA ST
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-2844
Practice Address - Country:US
Practice Address - Phone:808-304-3590
Practice Address - Fax:808-379-0468
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-22
Last Update Date:2021-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1-210057311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home