Healthcare Provider Details

I. General information

NPI: 1982632253
Provider Name (Legal Business Name): SKY PIERCE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4111 HANA HWY.
HANA HI
96713
US

IV. Provider business mailing address

PO BOX 931
HANA HI
96713-0931
US

V. Phone/Fax

Practice location:
  • Phone: 808-248-4850
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: