Provider First Line Business Practice Location Address: 
3175 ELUA ST STE C
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LIHUE
    Provider Business Practice Location Address State Name: 
HI
    Provider Business Practice Location Address Postal Code: 
96766-1203
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
808-212-9867
    Provider Business Practice Location Address Fax Number: 
434-333-7504
    Provider Enumeration Date: 
01/14/2018