Healthcare Provider Details

I. General information

NPI: 1821290917
Provider Name (Legal Business Name): ALFONSO F JIMENEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91-896 MAKULE RD SUITE 102
EWA BEACH HI
96706-2543
US

IV. Provider business mailing address

91-896 MAKULE RD SUITE 102
EWA BEACH HI
96706-2543
US

V. Phone/Fax

Practice location:
  • Phone: 808-689-4414
  • Fax: 808-689-7115
Mailing address:
  • Phone: 808-689-4414
  • Fax: 808-689-7115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALFONSO F JIMENEZ
Title or Position: OWNER
Credential: D.O.
Phone: 808-689-4414