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Registrant NPI Number: 1376794149

Individual Registrant:
Gender: M
Not Sole Proprietor

Location and contact information for practice:
17-195 IPUAIWAHA ST  KEAAU, HI 96749-8230 US
Tel: 808-966-8842  Fax: 808-966-8826

Contact information for business:
17-195 IPUAIWAHA ST  KEAAU, HI 96749-8230 US
Tel: 808-966-8842  Fax: 808-966-8826

Registration Information:
NPI: 1376794149
Entity Type: Individual

Specialty information:

PrimaryCodeCategory/DescriptionStateLicense Number
Y101Y00000XBehavioral Health & Social Service Providers

Legacy codes, insurance codes and state license numbers:



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