Healthcare Provider Details

I. General information

NPI: 1134700743
Provider Name (Legal Business Name): OHANA SPINE & ORTHO CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 US HIGHWAY 80 SW
POOLER GA
31322-2541
US

IV. Provider business mailing address

501 DRESLER RD
RINCON GA
31326-4749
US

V. Phone/Fax

Practice location:
  • Phone: 912-509-2892
  • Fax: 912-295-2678
Mailing address:
  • Phone: 912-509-2892
  • Fax: 912-295-2678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DANIELLE GILKEY
Title or Position: CEO
Credential:
Phone: 912-509-2892