MEDICARE: OHANA PREVENTATIVE MEDICINE 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	207Q00000X	Family Medicine Physician	2854334405	UT

General Provider Information

NPI Number	:	1578946737
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OHANA PREVENTATIVE MEDICINE LLC

Provider Business Mailing Address
First Line	:	3860 JACKSON AVE STE 7
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84403-1979
Country	:	US
Telephone Number	:	801-664-9501
Fax Number	:

Provider Business Practice Location Address
First Line	:	3860 JACKSON AVE STE 7
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84403-1979
Country	:	US
Telephone Number	:	801-664-9501
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TYSON S. OAKEY
Credential	:	FNP-BC
Telephone Number	:	801-668-1967

Provider Enumeration Date	:	07/07/2015
Last Update Date	:	07/07/2015

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