Healthcare Provider Details

I. General information

NPI: 1861388431
Provider Name (Legal Business Name): POMAIKAI WOUND CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2025
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 KILANI AVE
WAHIAWA HI
96786-2102
US

IV. Provider business mailing address

2008 INTERBAY ST
LAS VEGAS NV
89128-6799
US

V. Phone/Fax

Practice location:
  • Phone: 808-621-5042
  • Fax:
Mailing address:
  • Phone: 808-621-5042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JOHN COLLIS VISIT LACY
Title or Position: OWNER
Credential: APRN
Phone: 702-523-6615