Provider First Line Business Practice Location Address: 
4695 MAILIHUNA RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
KAPAA
    Provider Business Practice Location Address State Name: 
HI
    Provider Business Practice Location Address Postal Code: 
96746-2051
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
808-554-4787
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/05/2015