Healthcare Provider Details

I. General information

NPI: 1346363363
Provider Name (Legal Business Name): EYE CARE CENTER OF KAUAI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4366 KUKUI GROVE ST SUITE 101
LIHUE HI
96766-2006
US

IV. Provider business mailing address

4366 KUKUI GROVE ST SUITE 101
LIHUE HI
96766-2006
US

V. Phone/Fax

Practice location:
  • Phone: 808-246-0051
  • Fax: 808-246-4816
Mailing address:
  • Phone: 808-246-0051
  • Fax: 808-246-4816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD601
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code156FX1100X
TaxonomyOphthalmic Technician/Technologist
License NumberMD5846
License Number StateHI

VIII. Authorized Official

Name: DR. TIMOTHY L LEE
Title or Position: MEMBER
Credential: MD
Phone: 808-246-0051