1427392950 NPI number — JILL C. PETERSON LLC

Table of content: (NPI 1427392950)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427392950 NPI number — JILL C. PETERSON LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JILL C. PETERSON LLC
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:
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:
1427392950
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1759 IWI WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HONOLULU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96816-3826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-721-8048
Provider Business Mailing Address Fax Number:
808-394-2826

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6600 KALANIANAOLE HWY
Provider Second Line Business Practice Location Address:
SUITE 225
Provider Business Practice Location Address City Name:
HONOLULU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96825-1273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-721-8048
Provider Business Practice Location Address Fax Number:
808-394-2826
Provider Enumeration Date:
11/21/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PETERSON
Authorized Official First Name:
JILL
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
808-721-8048

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  946 , 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)