Healthcare Provider Details

I. General information

NPI: 1033387980
Provider Name (Legal Business Name): KAUAI DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4366 KUKUI GROVE ST SUITE 201
LIHUE HI
96766-2006
US

IV. Provider business mailing address

4366 KUKUI GROVE ST SUITE 201
LIHUE HI
96766-2006
US

V. Phone/Fax

Practice location:
  • Phone: 808-246-6904
  • Fax: 808-246-6081
Mailing address:
  • Phone: 808-246-6904
  • Fax: 808-246-6081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. CORINA E POTTER
Title or Position: OFFICE MANAGER
Credential:
Phone: 808-246-6904