Healthcare Provider Details

I. General information

NPI: 1669989117
Provider Name (Legal Business Name): INTELERETINA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2018
Last Update Date: 01/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 S KING ST STE 222
HONOLULU HI
96814-1701
US

IV. Provider business mailing address

PO BOX 31000 MAIL CODE 5769
HONOLULU HI
96849-5769
US

V. Phone/Fax

Practice location:
  • Phone: 808-277-6816
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: ERIC HANNUM
Title or Position: PRESIDENT
Credential:
Phone: 808-277-6816