Provider Demographics
NPI:1831483387
Name:KOVACH, BERNADETTE JENNIE (MT)
Entity Type:Individual
Prefix:MISS
First Name:BERNADETTE
Middle Name:JENNIE
Last Name:KOVACH
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 LEIHULU WAY
Mailing Address - Street 2:
Mailing Address - City:KULA
Mailing Address - State:HI
Mailing Address - Zip Code:96790-8283
Mailing Address - Country:US
Mailing Address - Phone:808-280-0306
Mailing Address - Fax:
Practice Address - Street 1:40 N MARKET ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1718
Practice Address - Country:US
Practice Address - Phone:808-242-8788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-01
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT11073171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor