Healthcare Provider Details

I. General information

NPI: 1164335980
Provider Name (Legal Business Name): SALLY JOSE BERMUDEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

679 MAIKA PL
WAILUKU HI
96793-5439
US

IV. Provider business mailing address

679 MAIKA PL
WAILUKU HI
96793-5439
US

V. Phone/Fax

Practice location:
  • Phone: 808-281-1105
  • Fax:
Mailing address:
  • Phone: 808-281-1105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: