Healthcare Provider Details

I. General information

NPI: 1912480237
Provider Name (Legal Business Name): ISLAND FAMILY SURGICAL CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 12/30/2020
Certification Date: 12/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 HUKU LII PL STE 304
KIHEI HI
96753-7062
US

IV. Provider business mailing address

411 HUKU LII PL STE 304
KIHEI HI
96753-7062
US

V. Phone/Fax

Practice location:
  • Phone: 808-868-2277
  • Fax: 808-439-6060
Mailing address:
  • Phone: 808-868-2277
  • Fax: 808-439-6060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. STEPHANIE ROSE YAN
Title or Position: MEMBER
Credential: MD
Phone: 88-682-2778