Healthcare Provider Details

I. General information

NPI: 1225005325
Provider Name (Legal Business Name): GRANT T MIYASHIRO OD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 03/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 W. KAWAILANI ST.
HILO HI
96720
US

IV. Provider business mailing address

34 W. KAWAILANI ST.
HILO HI
96720
US

V. Phone/Fax

Practice location:
  • Phone: 808-935-8887
  • Fax: 888-892-5882
Mailing address:
  • Phone: 808-935-8887
  • Fax: 888-892-5882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD422
License Number StateHI

VIII. Authorized Official

Name: GRANT TADASHI MIYASHIRO
Title or Position: PRINCIPAL/OPTOMETRIST
Credential: O.D.
Phone: 808-935-8887