Provider Demographics
NPI:1407963606
Name:PACIFIC TRAINING PROGRAM
Entity Type:Organization
Organization Name:PACIFIC TRAINING PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:ICHINOTSUBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-488-6846
Mailing Address - Street 1:99-128 AIEA HEIGHTS DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-3925
Mailing Address - Country:US
Mailing Address - Phone:808-488-6846
Mailing Address - Fax:
Practice Address - Street 1:99-128 AIEA HEIGHTS DR
Practice Address - Street 2:SUITE 108
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-3925
Practice Address - Country:US
Practice Address - Phone:808-488-6846
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-11341208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI51484202Medicaid
HIF34374Medicare UPIN