Provider First Line Business Practice Location Address: 
4370 KUKUI GROVE STREET
    Provider Second Line Business Practice Location Address: 
SUITE 3-211
    Provider Business Practice Location Address City Name: 
LIHUE
    Provider Business Practice Location Address State Name: 
HI
    Provider Business Practice Location Address Postal Code: 
96766
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
541-673-0057
    Provider Business Practice Location Address Fax Number: 
541-673-2270
    Provider Enumeration Date: 
02/20/2007