Provider Demographics
NPI:1295487882
Name:634 KALIHI MEDICAL AND WELLNESS CLINIC, LLC
Entity type:Organization
Organization Name:634 KALIHI MEDICAL AND WELLNESS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:RODRIGO
Authorized Official - Middle Name:GOSE
Authorized Official - Last Name:BRISTOL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-845-3911
Mailing Address - Street 1:634 KALIHI ST.
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819
Mailing Address - Country:US
Mailing Address - Phone:808-845-3911
Mailing Address - Fax:
Practice Address - Street 1:634 KALIHI ST.
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819
Practice Address - Country:US
Practice Address - Phone:808-845-3911
Practice Address - Fax:808-848-0870
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:634 KALIHI MEDICAL AND WELLNESS CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty