Healthcare Provider Details

I. General information

NPI: 1578946737
Provider Name (Legal Business Name): OHANA PREVENTATIVE MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3860 JACKSON AVE STE 7
OGDEN UT
84403-1979
US

IV. Provider business mailing address

3860 JACKSON AVE STE 7
OGDEN UT
84403-1979
US

V. Phone/Fax

Practice location:
  • Phone: 801-664-9501
  • Fax:
Mailing address:
  • Phone: 801-664-9501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2854334405
License Number StateUT

VIII. Authorized Official

Name: TYSON S. OAKEY
Title or Position: OWNER
Credential: FNP-BC
Phone: 801-668-1967