Healthcare Provider Details

I. General information

NPI: 1568214880
Provider Name (Legal Business Name): WARREN BUENAVISTA DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75-1029 HENRY ST STE 101
KAILUA KONA HI
96740-1666
US

IV. Provider business mailing address

PO BOX 950
CAPTAIN COOK HI
96704-0950
US

V. Phone/Fax

Practice location:
  • Phone: 808-334-0806
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-5872
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: