MEDICARE: EARTHLY BALANCE MENTAL WELLNESS

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1841142189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EARTHLY BALANCE MENTAL WELLNESS

Provider Business Mailing Address
First Line	:	200 N VINEYARD BLVD STE A325-439
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96817-3950
Country	:	US
Telephone Number	:	808-646-3782
Fax Number	:	808-336-2112

Provider Business Practice Location Address
First Line	:	200 N VINEYARD BLVD STE A325-439
Second Line	:
City	:	HONOLULU
State	:	HI
Zip	:	96817-3950
Country	:	US
Telephone Number	:	808-646-3782
Fax Number	:	808-336-2112

Authorized Official
Title or Position	:	OWNER
Name	:	MEMPHIS CHARDELL SANDOVAL
Credential	:	PMHNP-BC
Telephone Number	:	808-646-3782

Provider Enumeration Date	:	02/10/2026
Last Update Date	:	02/10/2026

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