Provider First Line Business Practice Location Address: 
3-3420B KUHIO HWY
    Provider Second Line Business Practice Location Address: 
STE B
    Provider Business Practice Location Address City Name: 
LIHUE
    Provider Business Practice Location Address State Name: 
HI
    Provider Business Practice Location Address Postal Code: 
96766-1042
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
808-245-1010
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/24/2018