Provider Demographics
NPI:1356149892
Name:THE MAKANA NORTH SHORE CLINIC
Entity type:Organization
Organization Name:THE MAKANA NORTH SHORE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:KIMBALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-581-4623
Mailing Address - Street 1:4488 HANALEI PLANTATION RD
Mailing Address - Street 2:
Mailing Address - City:PRINCEVILLE
Mailing Address - State:HI
Mailing Address - Zip Code:96722-5462
Mailing Address - Country:US
Mailing Address - Phone:808-320-7300
Mailing Address - Fax:
Practice Address - Street 1:4488 HANALEI PLANTATION RD
Practice Address - Street 2:
Practice Address - City:PRINCEVILLE
Practice Address - State:HI
Practice Address - Zip Code:96722-5462
Practice Address - Country:US
Practice Address - Phone:808-320-7300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE MAKANA NORTH SHORE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty