Healthcare Provider Details

I. General information

NPI: 1053809467
Provider Name (Legal Business Name): HAWAIIAN JELLYS, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5477 TIGER BEND LN
MORRISON CO
80465-9679
US

IV. Provider business mailing address

151 SUMMER ST UNIT 563
MORRISON CO
80465-3420
US

V. Phone/Fax

Practice location:
  • Phone: 303-697-0223
  • Fax:
Mailing address:
  • Phone: 303-697-0223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: PAUL JOSEPH GERSTENBERGER
Title or Position: CEO
Credential:
Phone: 303-697-0223