Provider Demographics
NPI:1245565613
Name:KAILUA WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:KAILUA WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:D
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:808-261-8181
Mailing Address - Street 1:228 KUULEI RD
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-2720
Mailing Address - Country:US
Mailing Address - Phone:808-261-8181
Mailing Address - Fax:808-261-7770
Practice Address - Street 1:228 KUULEI RD
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-2720
Practice Address - Country:US
Practice Address - Phone:808-261-8181
Practice Address - Fax:808-261-7770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-02
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI404111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH0000QCCDSMedicare PIN