MEDICARE: PACIFIC CENTRE FOR FAMILY HEALTH AND WELLNESS CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	DOS-515	HI

General Provider Information

NPI Number	:	1285876193
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFIC CENTRE FOR FAMILY HEALTH AND WELLNESS CORP

Provider Business Mailing Address
First Line	:	4725 BOUGAINVILLE DR
Second Line	:	PMB528
City	:	HONOLULU
State	:	HI
Zip	:	96818-3179
Country	:	US
Telephone Number	:	808-292-0763
Fax Number	:	414-247-9004

Provider Business Practice Location Address
First Line	:	4725 BOUGAINVILLE DR
Second Line	:	PMB528
City	:	HONOLULU
State	:	HI
Zip	:	96818-3179
Country	:	US
Telephone Number	:	808-292-0763
Fax Number	:	414-247-9004

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. FRED LEE GOLDBLATT
Credential	:	DO
Telephone Number	:	808-292-0763

Provider Enumeration Date	:	03/24/2009
Last Update Date	:	03/24/2009

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