Provider First Line Business Practice Location Address: 
91-2135 FORT WEAVER RD
    Provider Second Line Business Practice Location Address: 
#150
    Provider Business Practice Location Address City Name: 
EWA BEACH
    Provider Business Practice Location Address State Name: 
HI
    Provider Business Practice Location Address Postal Code: 
96706-1940
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
808-676-5331
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/29/2014