Provider Demographics
NPI:1578946737
Name:OHANA PREVENTATIVE MEDICINE LLC
Entity Type:Organization
Organization Name:OHANA PREVENTATIVE MEDICINE LLC
Other - Org Name:OPM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYSON
Authorized Official - Middle Name:S
Authorized Official - Last Name:OAKEY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:801-668-1967
Mailing Address - Street 1:3860 JACKSON AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1979
Mailing Address - Country:US
Mailing Address - Phone:801-664-9501
Mailing Address - Fax:
Practice Address - Street 1:3860 JACKSON AVE STE 7
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1979
Practice Address - Country:US
Practice Address - Phone:801-664-9501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2854334405207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty