Provider Demographics
NPI:1558803668
Name:SUNSHINE PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:SUNSHINE PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHALLON
Authorized Official - Middle Name:TORE
Authorized Official - Last Name:CRADDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-315-1519
Mailing Address - Street 1:2250 KAUMANA DR
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-1316
Mailing Address - Country:US
Mailing Address - Phone:808-315-1886
Mailing Address - Fax:
Practice Address - Street 1:199 ULULANI ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2930
Practice Address - Country:US
Practice Address - Phone:808-315-1886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD17956261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care