Healthcare Provider Details

I. General information

NPI: 1871819318
Provider Name (Legal Business Name): WAVES OF HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2010
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68-615 FARRINGTON HWY 21A
WAIALUA HI
96791-9377
US

IV. Provider business mailing address

68-615 FARRINGTON HWY 21A
WAIALUA HI
96791-9377
US

V. Phone/Fax

Practice location:
  • Phone: 303-882-7739
  • Fax:
Mailing address:
  • Phone: 303-882-7739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberMD-15206
License Number StateHI

VIII. Authorized Official

Name: DR. CLAYTON AUSTIN EVERLINE
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 303-882-7739