Provider Demographics
NPI:1255842092
Name:TEAM MAKENA LLC
Entity Type:Organization
Organization Name:TEAM MAKENA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ERNESTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-382-3919
Mailing Address - Street 1:27051 TOWNE CENTRE DR STE 180
Mailing Address - Street 2:
Mailing Address - City:FOOTHILL RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92610-2819
Mailing Address - Country:US
Mailing Address - Phone:800-996-4001
Mailing Address - Fax:
Practice Address - Street 1:500 ALA MOANA BLVD STE 400
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-4920
Practice Address - Country:US
Practice Address - Phone:949-474-1753
Practice Address - Fax:949-251-5120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-19
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier