1780975904 NPI number — KEALANI SINE MD INC

Table of content: (NPI 1780975904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780975904 NPI number — KEALANI SINE MD INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEALANI SINE MD INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PINE STREET PEDIATRICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780975904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7096
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95267-0096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-956-7725
Provider Business Mailing Address Fax Number:
209-956-7733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
216 E PINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EXETER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93221-1750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-302-7456
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/21/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SINE
Authorized Official First Name:
KEALANI
Authorized Official Middle Name:
KANEHE
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
559-302-7456

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  A61936 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)