Provider Demographics
NPI:1871819318
Name:WAVES OF HEALTH LLC
Entity Type:Organization
Organization Name:WAVES OF HEALTH LLC
Other - Org Name:BOARDSPORTSDOC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:AUSTIN
Authorized Official - Last Name:EVERLINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-882-7739
Mailing Address - Street 1:68-615 FARRINGTON HWY
Mailing Address - Street 2:21A
Mailing Address - City:WAIALUA
Mailing Address - State:HI
Mailing Address - Zip Code:96791-9377
Mailing Address - Country:US
Mailing Address - Phone:303-882-7739
Mailing Address - Fax:
Practice Address - Street 1:68-615 FARRINGTON HWY
Practice Address - Street 2:21A
Practice Address - City:WAIALUA
Practice Address - State:HI
Practice Address - Zip Code:96791-9377
Practice Address - Country:US
Practice Address - Phone:303-882-7739
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-08
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD-15206207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ139730L6FMedicare UPIN