Healthcare Provider Details

I. General information

NPI: 1467884536
Provider Name (Legal Business Name): ALOHA DERMATOLOGY AND LASER CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2013
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 HOOKELE ST 101
KAHULUI HI
96732-3532
US

IV. Provider business mailing address

PO BOX 668
PUUNENE HI
96784-0668
US

V. Phone/Fax

Practice location:
  • Phone: 808-877-6526
  • Fax: 808-877-7033
Mailing address:
  • Phone: 808-877-6526
  • Fax: 808-877-7033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICKI N LY
Title or Position: CEO
Credential: MD
Phone: 808-877-6526