Provider Demographics
NPI:1285876193
Name:PACIFIC CENTRE FOR FAMILY HEALTH AND WELLNESS CORP
Entity type:Organization
Organization Name:PACIFIC CENTRE FOR FAMILY HEALTH AND WELLNESS CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GOLDBLATT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:808-292-0763
Mailing Address - Street 1:4725 BOUGAINVILLE DR
Mailing Address - Street 2:PMB528
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-3179
Mailing Address - Country:US
Mailing Address - Phone:808-292-0763
Mailing Address - Fax:414-247-9004
Practice Address - Street 1:4725 BOUGAINVILLE DR
Practice Address - Street 2:PMB528
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96818-3179
Practice Address - Country:US
Practice Address - Phone:808-292-0763
Practice Address - Fax:414-247-9004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS-515207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty