1770512048 NPI number — ELAM SPORTS, INC.

Table of content: (NPI 1770512048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770512048 NPI number — ELAM SPORTS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELAM SPORTS, INC.
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:
ELAM SPORTS OAHU
Provider Other Organization Name Type Code:
3
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:
1770512048
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 KAMOKILA BLVD
Provider Second Line Business Mailing Address:
SUITE 111 JCB
Provider Business Mailing Address City Name:
KAPOLEI
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96707-2014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-674-9595
Provider Business Mailing Address Fax Number:
808-674-9696

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 KAMEHAMEHA HWY
Provider Second Line Business Practice Location Address:
SUITE 2B
Provider Business Practice Location Address City Name:
PEARL CITY
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96782-3238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-674-9595
Provider Business Practice Location Address Fax Number:
808-674-9696
Provider Enumeration Date:
06/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ELAM
Authorized Official First Name:
CHANDRA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
COMPANY OFFICER
Authorized Official Telephone Number:
808-674-9595

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 50320201 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: A218931 . This is a "HMSA" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".




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