Healthcare Provider Details

I. General information

NPI: 1346540424
Provider Name (Legal Business Name): ISLAND SPORTS CHIROPRACTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2010
Last Update Date: 10/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 AKAHI ST
LIHUE HI
96766-1106
US

IV. Provider business mailing address

3125 AKAHI ST
LIHUE HI
96766-1106
US

V. Phone/Fax

Practice location:
  • Phone: 808-245-7100
  • Fax: 808-245-7260
Mailing address:
  • Phone: 808-245-7100
  • Fax: 808-245-7260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberW74733239-01
License Number StateHI

VIII. Authorized Official

Name: DR. AARIES T ODA
Title or Position: OWNER
Credential: D.C.
Phone: 808-245-7100