Healthcare Provider Details

I. General information

NPI: 1164506549
Provider Name (Legal Business Name): GLORIA N CARLILE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 NORTH KALAHEO AVE C103
KAILUA HI
96734
US

IV. Provider business mailing address

970 NORTH KALAHEO AVE C103
KAILUA HI
96734
US

V. Phone/Fax

Practice location:
  • Phone: 808-254-6474
  • Fax: 808-254-6400
Mailing address:
  • Phone: 808-254-6474
  • Fax: 808-254-6400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD5564
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: