Healthcare Provider Details

I. General information

NPI: 1881437168
Provider Name (Legal Business Name): SKIN KAHALA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4819 KILAUEA AVE STE 7
HONOLULU HI
96816-5712
US

IV. Provider business mailing address

4819 KILAUEA AVE STE 7
HONOLULU HI
96816-5712
US

V. Phone/Fax

Practice location:
  • Phone: 310-709-5492
  • Fax: 808-808-1324
Mailing address:
  • Phone: 310-709-5492
  • Fax: 808-808-1324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TARYN WRIGHT
Title or Position: PRACTICE MANAGER
Credential:
Phone: 808-808-1324