MEDICARE: ASENTRA MARKETING

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	261QM1300X	Multi-Specialty Clinic/Center
2	261QU0200X	Urgent Care Clinic/Center

General Provider Information

NPI Number	:	1811307093
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASENTRA MARKETING

Provider Business Mailing Address
First Line	:	4725 BOUGAINVILLE DR
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96818-3179
Country	:	US
Telephone Number	:	203-650-6922
Fax Number	:

Provider Business Practice Location Address
First Line	:	4725 BOUGAINVILLE DR
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96818-3179
Country	:	US
Telephone Number	:	203-650-6922
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. DAVE GRUBLER
Credential	:	CEO
Telephone Number	:	203-650-6922

Provider Enumeration Date	:	04/28/2014
Last Update Date	:	04/28/2014

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Directions to “ASENTRA MARKETING ” Practice Location

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