Healthcare Provider Details

I. General information

NPI: 1770897324
Provider Name (Legal Business Name): PACIFIC ENTERPRISE GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2010
Last Update Date: 08/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98-501 KOAUKA LOOP A-702
AIEA HI
96701-4550
US

IV. Provider business mailing address

PO BOX 276
AIEA HI
96701-0276
US

V. Phone/Fax

Practice location:
  • Phone: 808-927-9038
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPSY1077
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY1077
License Number StateHI

VIII. Authorized Official

Name: DR. CHARLES THOMAS HARDING
Title or Position: DIRECTOR
Credential: PSY.D., M.A.
Phone: 808-927-9038