Healthcare Provider Details

I. General information

NPI: 1629833934
Provider Name (Legal Business Name): PEGASUS REALM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2024
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 OPIHIKAO PL
HONOLULU HI
96825-1131
US

IV. Provider business mailing address

402 OPIHIKAO PL
HONOLULU HI
96825-1131
US

V. Phone/Fax

Practice location:
  • Phone: 808-763-0107
  • Fax:
Mailing address:
  • Phone: 808-763-0107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: MR. ADAM GRIMM
Title or Position: FOUNDER
Credential:
Phone: 808-763-0107