Basic Information
| Provider Information | |||||||||
| NPI: | 1164764957 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACADEMY FOOT CENTER OF HAWAII, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2980 N BEVERLY GLEN CIR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900771726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104749809 | ||||||||
| FaxNumber: | 8884318819 | ||||||||
| Practice Location | |||||||||
| Address1: | 1329 LUSITANA ST | ||||||||
| Address2: | SUITE 801 | ||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968132429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085364335 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2013 | ||||||||
| LastUpdateDate: | 10/05/2015 | ||||||||
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| AuthorizedOfficialLastName: | PASCUAL | ||||||||
| AuthorizedOfficialFirstName: | GRACE | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8085364335 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ACADEMY FOOT CENTER OF HAWAII, INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.