Healthcare Provider Details

I. General information

NPI: 1942518022
Provider Name (Legal Business Name): ISLAND HEART CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 12/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75-167 HUALALAI RD
KAILUA KONA HI
96740-1714
US

IV. Provider business mailing address

75-167 HUALALAI RD
KAILUA KONA HI
96740-1714
US

V. Phone/Fax

Practice location:
  • Phone: 808-769-5225
  • Fax: 808-769-5099
Mailing address:
  • Phone: 808-769-5225
  • Fax: 808-769-5099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberMD-11161
License Number StateHI

VIII. Authorized Official

Name: MRS. APRIL MELODY JOHNSON
Title or Position: MANAGER
Credential: LPN
Phone: 808-854-1162