Provider Demographics
NPI:1720377195
Name:KAUAI OPTOMETRIC CENTER LLC
Entity Type:Organization
Organization Name:KAUAI OPTOMETRIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:P
Authorized Official - Last Name:BELISLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:808-822-3733
Mailing Address - Street 1:4-901 KUHIO HWY
Mailing Address - Street 2:STE. B
Mailing Address - City:KAPAA
Mailing Address - State:HI
Mailing Address - Zip Code:96746-1576
Mailing Address - Country:US
Mailing Address - Phone:808-822-3733
Mailing Address - Fax:808-822-7355
Practice Address - Street 1:4-901 KUHIO HWY
Practice Address - Street 2:STE. B
Practice Address - City:KAPAA
Practice Address - State:HI
Practice Address - Zip Code:96746-1576
Practice Address - Country:US
Practice Address - Phone:808-822-3733
Practice Address - Fax:808-822-7355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-06
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIOD181152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIEZ700AMedicare PIN