Provider Demographics
NPI:1740836733
Name:J EDWARD DEBOARD MD LLC
Entity type:Organization
Organization Name:J EDWARD DEBOARD MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEBOARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-741-5646
Mailing Address - Street 1:1342 ALOHA OE DR
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-4508
Mailing Address - Country:US
Mailing Address - Phone:808-741-5646
Mailing Address - Fax:
Practice Address - Street 1:1329 LUSITANA ST STE 102
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2401
Practice Address - Country:US
Practice Address - Phone:808-533-1020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care