Healthcare Provider Details

I. General information

NPI: 1821409236
Provider Name (Legal Business Name): FACIAL808
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73-4520 HAWAII BELT ROAD
KAILUA-KONA HI
96740
US

IV. Provider business mailing address

73-4520 HAWAII BELT ROAD
KAILUA-KONA HI
96740
US

V. Phone/Fax

Practice location:
  • Phone: 808-457-0330
  • Fax:
Mailing address:
  • Phone: 808-457-0330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberMAT 3913
License Number StateHI

VIII. Authorized Official

Name: ELLARENE KUULEIALOHA VOGELGESANG
Title or Position: OWNER
Credential:
Phone: 808-457-0330