Provider Demographics
NPI:1417388760
Name:HICOM UNIVERSITY
Entity Type:Organization
Organization Name:HICOM UNIVERSITY
Other - Org Name:HAWAII COLLEGE OF ORIENTAL MEDICINE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BURTON
Authorized Official - Last Name:PETTIS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LAC, EAMP
Authorized Official - Phone:808-933-1369
Mailing Address - Street 1:180 KINOOLE ST STE 301
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-2827
Mailing Address - Country:US
Mailing Address - Phone:808-933-1369
Mailing Address - Fax:866-217-9199
Practice Address - Street 1:180 KINOOLE ST STE 301
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2827
Practice Address - Country:US
Practice Address - Phone:808-933-1369
Practice Address - Fax:866-217-9199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI671171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty