Provider Demographics
NPI:1225804511
Name:KAUAI RESTORATIVE SPORTS MEDICINE
Entity Type:Organization
Organization Name:KAUAI RESTORATIVE SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COS (CHIEF OF OTHER STUFF)
Authorized Official - Prefix:
Authorized Official - First Name:GISELLE
Authorized Official - Middle Name:H
Authorized Official - Last Name:GREGORIUS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LSW
Authorized Official - Phone:808-212-5100
Mailing Address - Street 1:2362 KIPUKA ST
Mailing Address - Street 2:
Mailing Address - City:KOLOA
Mailing Address - State:HI
Mailing Address - Zip Code:96756-9559
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2362 KIPUKA ST
Practice Address - Street 2:
Practice Address - City:KOLOA
Practice Address - State:HI
Practice Address - Zip Code:96756-9559
Practice Address - Country:US
Practice Address - Phone:808-755-8000
Practice Address - Fax:707-806-0234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine