=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114029865
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINA CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2006
-----------------------------------------------------
Last Update Date | 02/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2470 S KING ST
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96826-3013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-955-6800
-----------------------------------------------------
Fax | 808-955-6877
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2470 S KING ST
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96826-3013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-955-6800
-----------------------------------------------------
Fax | 808-955-6877
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. ADEL ETINAS
-----------------------------------------------------
Credential | R.PH
-----------------------------------------------------
Telephone | 808-222-9252
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | PHY-644
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------