Healthcare Provider Details

I. General information

NPI: 1902769607
Provider Name (Legal Business Name): AMPHORA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4236 CARNATION PL
HONOLULU HI
96816-3905
US

IV. Provider business mailing address

4236 CARNATION PL
HONOLULU HI
96816-3905
US

V. Phone/Fax

Practice location:
  • Phone: 831-359-9814
  • Fax:
Mailing address:
  • Phone: 831-359-9814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: GOVIND RAE
Title or Position: CEO
Credential:
Phone: 831-359-9814