Healthcare Provider Details

I. General information

NPI: 1417377649
Provider Name (Legal Business Name): PACIFIC ENDOSCOPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2014
Last Update Date: 11/10/2024
Certification Date: 11/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 PUUHONU WAY
HILO HI
96720-2066
US

IV. Provider business mailing address

134 PUUHONU WAY
HILO HI
96720-2066
US

V. Phone/Fax

Practice location:
  • Phone: 808-969-3979
  • Fax: 808-531-5819
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberFSOF-9
License Number StateHI

VIII. Authorized Official

Name: ERIC BOON
Title or Position: OFFICER/AO
Credential:
Phone: 480-567-0269