Basic Information
Provider Information | |||||||||
NPI: | 1669831913 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HAWAII METABOLIC MANAGEMENT, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OSR WEIGHT MANAGEMENT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 970 N KALAHEO AVE | ||||||||
Address2: | SUITE C-316 | ||||||||
City: | KAILUA | ||||||||
State: | HI | ||||||||
PostalCode: | 967341866 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8084885555 | ||||||||
FaxNumber: | 8083560664 | ||||||||
Practice Location | |||||||||
Address1: | 970 N KALAHEO AVE | ||||||||
Address2: | SUITE C-316 | ||||||||
City: | KAILUA | ||||||||
State: | HI | ||||||||
PostalCode: | 967341866 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8084885555 | ||||||||
FaxNumber: | 8083560664 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2016 | ||||||||
LastUpdateDate: | 02/15/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WELLS | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8084885555 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RB0002X |   | HI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Bariatric Medicine |
No ID Information.