Healthcare Provider Details

I. General information

NPI: 1376605550
Provider Name (Legal Business Name): PACIFIC PULMONARY CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 ELUA ST # A
LIHUE HI
96766-1212
US

IV. Provider business mailing address

PO BOX 3070
LIHUE HI
96766-6070
US

V. Phone/Fax

Practice location:
  • Phone: 808-245-5383
  • Fax:
Mailing address:
  • Phone: 808-245-5383
  • Fax: 808-245-5388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number10307
License Number StateHI

VIII. Authorized Official

Name: TAD JACKSON
Title or Position: OWNER
Credential: MD
Phone: 808-245-5383