Healthcare Provider Details

I. General information

NPI: 1770512048
Provider Name (Legal Business Name): ELAM SPORTS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 KAMEHAMEHA HWY SUITE 2B
PEARL CITY HI
96782-3238
US

IV. Provider business mailing address

1001 KAMOKILA BLVD SUITE 111 JCB
KAPOLEI HI
96707-2014
US

V. Phone/Fax

Practice location:
  • Phone: 808-674-9595
  • Fax: 808-674-9696
Mailing address:
  • Phone: 808-674-9595
  • Fax: 808-674-9696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: CHANDRA L ELAM
Title or Position: COMPANY OFFICER
Credential:
Phone: 808-674-9595