Basic Information
| Provider Information | |||||||||
| NPI: | 1093309577 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ENRICO | ||||||||
| FirstName: | JOHN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 87-1545 KUAHA ST | ||||||||
| Address2: | |||||||||
| City: | WAIANAE | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967925413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6319746606 | ||||||||
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| Practice Location | |||||||||
| Address1: | 203 KAPAA QUARRY PL | ||||||||
| Address2: | #5002 | ||||||||
| City: | KAILUA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8087412232 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2021 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.