=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164762753
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAWAII ADVANCED MEDICAL GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2013
-----------------------------------------------------
Last Update Date | 02/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1314 S KING ST SUITE #1564
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96814-1956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-238-1691
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 8544
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96830-0544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-238-1691
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | SUNG YANG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 808-238-1691
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | ACU833
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MAT12513
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------