Healthcare Provider Details

I. General information

NPI: 1598924797
Provider Name (Legal Business Name): HARRY BURGESS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 06/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85-979 MILL ST
WAIANAE HI
96792-2645
US

IV. Provider business mailing address

86-226 FARRINGTON HWY
WAIANAE HI
96792-3128
US

V. Phone/Fax

Practice location:
  • Phone: 808-696-9498
  • Fax: 808-696-9403
Mailing address:
  • Phone: 808-696-4211
  • Fax: 808-696-5516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: