Provider Demographics
NPI:1770897324
Name:PACIFIC ENTERPRISE GROUP, LLC
Entity type:Organization
Organization Name:PACIFIC ENTERPRISE GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:HARDING
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, MA
Authorized Official - Phone:808-927-9038
Mailing Address - Street 1:PO BOX 276
Mailing Address - Street 2:
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-0276
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:98-501 KOAUKA LOOP
Practice Address - Street 2:A-702
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-4550
Practice Address - Country:US
Practice Address - Phone:808-927-9038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY1077103TA0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty