Healthcare Provider Details

I. General information

NPI: 1114355088
Provider Name (Legal Business Name): ANDREW DEFOREST D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ANDREW DEFOREST D.AC

II. Dates (important events)

Enumeration Date: 10/31/2013
Last Update Date: 10/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

641 LUAHOANA PL
WAILUKU HI
96793-5411
US

IV. Provider business mailing address

641 LUAHOANA PL
WAILUKU HI
96793-5411
US

V. Phone/Fax

Practice location:
  • Phone: 808-283-2217
  • Fax: 808-283-2217
Mailing address:
  • Phone: 808-283-2217
  • Fax: 808-283-2217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number641
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: