Provider First Line Business Practice Location Address: 
99-1191 IWAENA ST
    Provider Second Line Business Practice Location Address: 
SUITE D
    Provider Business Practice Location Address City Name: 
AIEA
    Provider Business Practice Location Address State Name: 
HI
    Provider Business Practice Location Address Postal Code: 
96701-3259
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
808-486-7914
    Provider Business Practice Location Address Fax Number: 
808-486-7915
    Provider Enumeration Date: 
09/26/2006