Provider Demographics
NPI: | 1700498680 |
---|---|
Name: | BLANE K. CHONG, MD SPORTS MEDICINE AND FAMILY PRACTICE LLC |
Entity Type: | Organization |
Organization Name: | BLANE K. CHONG, MD SPORTS MEDICINE AND FAMILY PRACTICE LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OFFICE MANAGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JASMINE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | KAUKA |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 808-732-9710 |
Mailing Address - Street 1: | 3221 WAIALAE AVE STE 390 |
Mailing Address - Street 2: | |
Mailing Address - City: | HONOLULU |
Mailing Address - State: | HI |
Mailing Address - Zip Code: | 96816-5850 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 808-732-9710 |
Mailing Address - Fax: | 808-732-9720 |
Practice Address - Street 1: | 3221 WAIALAE AVE STE 390 |
Practice Address - Street 2: | |
Practice Address - City: | HONOLULU |
Practice Address - State: | HI |
Practice Address - Zip Code: | 96816-5850 |
Practice Address - Country: | US |
Practice Address - Phone: | 808-732-9710 |
Practice Address - Fax: | 808-732-9720 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2020-08-20 |
Last Update Date: | 2021-04-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QP2300X | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |