Healthcare Provider Details

I. General information

NPI: 1912966474
Provider Name (Legal Business Name): DAVID KEIKI MAI LANI LOUIS HALEY SR. IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SEAL BEACH BLVD BLDG 77
SEAL BEACH CA
90740-5607
US

IV. Provider business mailing address

800 SEAL BEACH BLVD BLDG 77
SEAL BEACH CA
90740-5607
US

V. Phone/Fax

Practice location:
  • Phone: 562-626-6296
  • Fax: 562-626-6290
Mailing address:
  • Phone: 562-626-6296
  • Fax: 562-626-6290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: