Provider First Line Business Practice Location Address: 
504 LIHOLIHO ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WAILUKU
    Provider Business Practice Location Address State Name: 
HI
    Provider Business Practice Location Address Postal Code: 
96793-2615
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
904-563-5389
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/24/2020