Provider Demographics
NPI:1851647952
Name:VENTURE MEDICAL 21 INC
Entity Type:Organization
Organization Name:VENTURE MEDICAL 21 INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:D
Authorized Official - Last Name:REQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-531-7878
Mailing Address - Street 1:810 RICHARDS ST STE 990
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-4722
Mailing Address - Country:US
Mailing Address - Phone:808-531-7878
Mailing Address - Fax:808-531-7829
Practice Address - Street 1:91-896 MAKULE RD STE 102
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-2543
Practice Address - Country:US
Practice Address - Phone:808-689-4414
Practice Address - Fax:808-689-7115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-26
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIW8141213401OtherSTATE OF HAWAII