Provider Demographics
NPI:1689056350
Name:NONE
Entity type:Organization
Organization Name:NONE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STUDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:TIANA ROSE
Authorized Official - Middle Name:L
Authorized Official - Last Name:AHUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-223-0936
Mailing Address - Street 1:58-290 KAMEHAMEHA HWY
Mailing Address - Street 2:
Mailing Address - City:HALEIWA
Mailing Address - State:HI
Mailing Address - Zip Code:96712-9716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:58-290 KAMEHAMEHA HWY
Practice Address - Street 2:
Practice Address - City:HALEIWA
Practice Address - State:HI
Practice Address - Zip Code:96712-9716
Practice Address - Country:US
Practice Address - Phone:808-223-0936
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty