Healthcare Provider Details

I. General information

NPI: 1487102877
Provider Name (Legal Business Name): KA WAI OLA MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16-590 OLD VOLCANO RD STE. A
KEAAU HI
96749-8158
US

IV. Provider business mailing address

1695 AUWAE RD
HILO HI
96720-6908
US

V. Phone/Fax

Practice location:
  • Phone: 808-796-0168
  • Fax:
Mailing address:
  • Phone: 808-796-0168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberAPRN-1450
License Number StateHI

VIII. Authorized Official

Name: LEILANI KERR
Title or Position: OWNER
Credential: APRN
Phone: 808-796-0168