1801192620 NPI number — OUTRIGGER SHOPS, LTD.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801192620 NPI number — OUTRIGGER SHOPS, LTD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OUTRIGGER SHOPS, LTD.
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:
Provider Other Organization Name Type Code:
6
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:
1801192620
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2330 KUHIO AVE
Provider Second Line Business Mailing Address:
MEZZANINE FLOOR
Provider Business Mailing Address City Name:
HONOLULU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96815-2951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-923-2057
Provider Business Mailing Address Fax Number:
808-922-4393

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1922 KALAKAUA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HONOLULU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96815-1854
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-942-1922
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/27/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NORSTROM
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
808-923-2057

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PHY795 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 685092 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".