=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215124656
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESORT MEDICINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2007
-----------------------------------------------------
Last Update Date | 10/01/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3860 WAILEA ALANUI DR SUITE 102
-----------------------------------------------------
City | WAILEA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96753-8447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-891-1111
-----------------------------------------------------
Fax | 808-891-1123
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3860 WAILEA ALANUI DR SUITE 102
-----------------------------------------------------
City | WAILEA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96753-8447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-891-1111
-----------------------------------------------------
Fax | 808-891-1123
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MR. JOSHUA D BIRD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 808-891-1111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number | W27220253-01
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------