Healthcare Provider Details

I. General information

NPI: 1063575892
Provider Name (Legal Business Name): SAMANTHA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75-5995 KUAKINI HWY SUITE 445
KAILUA KONA HI
96740-2144
US

IV. Provider business mailing address

75-5995 KUAKINI HWY SUITE 445
KAILUA KONA HI
96740-2144
US

V. Phone/Fax

Practice location:
  • Phone: 808-326-2873
  • Fax: 808-326-9530
Mailing address:
  • Phone: 808-326-2873
  • Fax: 808-326-9530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number11969
License Number StateHI

VIII. Authorized Official

Name: DR. MARY JANE SUNGA CASTRO
Title or Position: PHYSICIAN MEMBER
Credential: MD
Phone: 808-326-2873