Provider First Line Business Practice Location Address: 
67-1123 MAMALAHOA HWY
    Provider Second Line Business Practice Location Address: 
SUITE 120
    Provider Business Practice Location Address City Name: 
KAMUELA
    Provider Business Practice Location Address State Name: 
HI
    Provider Business Practice Location Address Postal Code: 
96743-8451
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
808-885-5236
    Provider Business Practice Location Address Fax Number: 
808-885-4126
    Provider Enumeration Date: 
06/11/2009