Provider Demographics
NPI:1053582429
Name:IMUA KAUAI FOOTCARE
Entity type:Organization
Organization Name:IMUA KAUAI FOOTCARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAND
Authorized Official - Middle Name:D
Authorized Official - Last Name:MUNDO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:808-935-3121
Mailing Address - Street 1:PO BOX 10898
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96721-5898
Mailing Address - Country:US
Mailing Address - Phone:808-935-3121
Mailing Address - Fax:
Practice Address - Street 1:1028 KINOOLE ST STE 104
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-3800
Practice Address - Country:US
Practice Address - Phone:808-935-3121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPO-105213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI4243030001Medicare NSC