Healthcare Provider Details

I. General information

NPI: 1699127332
Provider Name (Legal Business Name): HAWAII WELLNESS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2016
Last Update Date: 01/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 S KING ST STE 1655
HONOLULU HI
96814-1950
US

IV. Provider business mailing address

1314 S KING ST STE 1653
HONOLULU HI
96814-1950
US

V. Phone/Fax

Practice location:
  • Phone: 808-591-9339
  • Fax: 808-591-9343
Mailing address:
  • Phone: 808-591-9339
  • Fax: 808-591-9343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DAMIAN SMITH
Title or Position: OWNER
Credential:
Phone: 808-591-9339