Provider Demographics
NPI:1487130217
Name:JULIAN, EREDULIN VIGILLA
Entity type:Individual
Prefix:
First Name:EREDULIN
Middle Name:VIGILLA
Last Name:JULIAN
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:PO BOX 966
Mailing Address - Street 2:
Mailing Address - City:PAHOA
Mailing Address - State:HI
Mailing Address - Zip Code:96778-0966
Mailing Address - Country:US
Mailing Address - Phone:808-936-9394
Mailing Address - Fax:808-498-0803
Practice Address - Street 1:15-3226 HOOPILI ST
Practice Address - Street 2:
Practice Address - City:PAHOA
Practice Address - State:HI
Practice Address - Zip Code:96778-6708
Practice Address - Country:US
Practice Address - Phone:808-965-9182
Practice Address - Fax:808-498-0803
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-15
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIH1080813287376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI12104Medicaid
HI$$$$$$$$$Medicaid