=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184206799
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEALOHANANI LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2021
-----------------------------------------------------
Last Update Date | 04/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 65-1235A OPELO RD STE 1
-----------------------------------------------------
City | KAMUELA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96743-8401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-885-5392
-----------------------------------------------------
Fax | 808-885-5392
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 65-1235A OPELO RD STE 1
-----------------------------------------------------
City | KAMUELA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96743-8401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-885-5392
-----------------------------------------------------
Fax | 808-885-5392
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LOKENANI K SOUZA
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 808-557-3540
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------