Provider Demographics
NPI:1629833934
Name:PEGASUS REALM LLC
Entity Type:Organization
Organization Name:PEGASUS REALM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-763-0107
Mailing Address - Street 1:402 OPIHIKAO PL
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96825-1131
Mailing Address - Country:US
Mailing Address - Phone:808-763-0107
Mailing Address - Fax:
Practice Address - Street 1:402 OPIHIKAO PL
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96825-1131
Practice Address - Country:US
Practice Address - Phone:808-763-0107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171400000XOther Service ProvidersHealth & Wellness CoachGroup - Single Specialty