Healthcare Provider Details

I. General information

NPI: 1720377195
Provider Name (Legal Business Name): KAUAI OPTOMETRIC CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4-901 KUHIO HWY STE. B
KAPAA HI
96746-1576
US

IV. Provider business mailing address

4-901 KUHIO HWY STE. B
KAPAA HI
96746-1576
US

V. Phone/Fax

Practice location:
  • Phone: 808-822-3733
  • Fax: 808-822-7355
Mailing address:
  • Phone: 808-822-3733
  • Fax: 808-822-7355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD181
License Number StateHI

VIII. Authorized Official

Name: DR. GLENN P BELISLE
Title or Position: OWNER
Credential: OD
Phone: 808-822-3733