Provider Demographics
NPI:1720195399
Name:TRACI L. SCHMALLE, O.D., LLC
Entity Type:Organization
Organization Name:TRACI L. SCHMALLE, O.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:L S
Authorized Official - Last Name:SCHMALLE-JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:808-455-5650
Mailing Address - Street 1:94-348 LELEAKA ST
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-2213
Mailing Address - Country:US
Mailing Address - Phone:808-455-5650
Mailing Address - Fax:808-455-5625
Practice Address - Street 1:1131 KUALA ST
Practice Address - Street 2:C/O THE VISION CENTER
Practice Address - City:PEARL CITY
Practice Address - State:HI
Practice Address - Zip Code:96782
Practice Address - Country:US
Practice Address - Phone:808-455-5650
Practice Address - Fax:808-455-5625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI594152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIU85978Medicare UPIN
HI101284Medicare ID - Type Unspecified