MEDICARE: PACIFIC ENDOSCOPY CENTER LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center	FSOF-9	HI

General Provider Information

NPI Number	:	1417377649
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFIC ENDOSCOPY CENTER LLC

Provider Business Mailing Address
First Line	:	134 PUUHONU WAY
Second Line	:
City	:	HILO
State	:	HI
Zip	:	96720-2066
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	134 PUUHONU WAY
Second Line	:
City	:	HILO
State	:	HI
Zip	:	96720-2066
Country	:	US
Telephone Number	:	808-969-3979
Fax Number	:	808-531-5819

Authorized Official
Title or Position	:	OFFICER/AO
Name	:	ERIC BOON
Credential	:
Telephone Number	:	480-567-0269

Provider Enumeration Date	:	04/28/2014
Last Update Date	:	11/10/2024

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