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General NPI Number Information
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NPI Number | 1871091801
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Entity Type | Organization
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Legal Business Name | MAUNA KEA MEDICAL LLC
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Dates
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Enumeration Date | 01/24/2018
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Last Update Date | 01/24/2018
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Provider Practice Location Address
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Address Line | 64-1035 MAMALAHOA HWY STE K
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City | KAMUELA
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State | HI
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Zip | 96743-8440
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Country | US
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Telephone | 808-883-9785
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Fax | 808-883-9683
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Provider Business Mailing Address
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Address Line | 64-1035 MAMALAHOA HWY STE K
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City | KAMUELA
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State | HI
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Zip | 96743-8440
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Country | US
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Telephone | 808-883-9785
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Fax | 808-883-9683
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Authorized Official
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Title or Position | DELEGATED OFFICIAL
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Name | DR. JOHN DOUGLAS STOVER
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Credential |
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Telephone | 808-960-5412
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 18437
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License Number State | HI
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