Healthcare Provider Details

I. General information

NPI: 1164804076
Provider Name (Legal Business Name): TOTAL DEFENSE SYSTEM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2015
Last Update Date: 06/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94-530 UKEE ST
WAIPAHU HI
96797-4213
US

IV. Provider business mailing address

94-530 UKEE ST
WAIPAHU HI
96797-4213
US

V. Phone/Fax

Practice location:
  • Phone: 808-271-2423
  • Fax:
Mailing address:
  • Phone: 808-271-2423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number StateHI

VIII. Authorized Official

Name: JEWELZ J LEE
Title or Position: MANAGER/CO-OWNER
Credential:
Phone: 808-271-2423