Provider Demographics
NPI:1083154751
Name:PUEO FAMILY PRACTICE
Entity Type:Organization
Organization Name:PUEO FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BEKKUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-573-2222
Mailing Address - Street 1:1120A MAKAWAO AVE
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-9448
Mailing Address - Country:US
Mailing Address - Phone:808-573-2222
Mailing Address - Fax:808-573-2224
Practice Address - Street 1:1120A MAKAWAO AVE
Practice Address - Street 2:
Practice Address - City:MAKAWAO
Practice Address - State:HI
Practice Address - Zip Code:96768-9448
Practice Address - Country:US
Practice Address - Phone:808-573-2222
Practice Address - Fax:808-573-2224
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST MAUI MEDICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-17180261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center