MEDICARE: MR. DAVID KEIKI MAI LANI LOUIS HALEY SR. IDC

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	1710I1002X	Independent Duty Corpsman

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	040819701988	OTHER	CA	INDEPENDENT DUTY CORPSMAN

General Provider Information

NPI Number	:	1912966474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID KEIKI MAI LANI LOUIS HALEY SR. IDC

Provider Business Mailing Address
First Line	:	800 SEAL BEACH BLVD
Second Line	:	BLDG 77
City	:	SEAL BEACH
State	:	CA
Zip	:	90740-5607
Country	:	US
Telephone Number	:	562-626-6296
Fax Number	:	562-626-6290

Provider Business Practice Location Address
First Line	:	800 SEAL BEACH BLVD
Second Line	:	BLDG 77
City	:	SEAL BEACH
State	:	CA
Zip	:	90740-5607
Country	:	US
Telephone Number	:	562-626-6296
Fax Number	:	562-626-6290

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2006
Last Update Date	:	07/08/2007

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Directions to “ MR. DAVID KEIKI MAI LANI LOUIS HALEY SR. IDC” Practice Location

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