Provider Demographics
NPI:1659080901
Name:OUTREACH MEDICAL GROUP DOWNTOWN LLC
Entity Type:Organization
Organization Name:OUTREACH MEDICAL GROUP DOWNTOWN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:M
Authorized Official - Last Name:TENGAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:808-845-5550
Mailing Address - Street 1:94-449 AKOKI ST STE 104
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-2732
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:928 NUUANU AVE # 1-C
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-5190
Practice Address - Country:US
Practice Address - Phone:808-845-5550
Practice Address - Fax:808-845-5557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-15
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty