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	OHCA FSOF 15	HI

General Provider Information

NPI Number	:	1841316841
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFIC ENDOSCOPY CENTER, LLC

Provider Business Mailing Address
First Line	:	1029 MAKOLU ST STE H
Second Line	:
City	:	PEARL CITY
State	:	HI
Zip	:	96782-2890
Country	:	US
Telephone Number	:	615-345-6900
Fax Number	:

Provider Business Practice Location Address
First Line	:	1029 MAKOLU STREET
Second Line	:	SUITE H
City	:	PEARL CITY
State	:	HI
Zip	:	96782-2890
Country	:	US
Telephone Number	:	808-456-6420
Fax Number	:	808-456-6421

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	ERIC BOON
Credential	:
Telephone Number	:	480-567-0269

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	01/12/2025

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