Provider Demographics
NPI:1396355616
Name:ISLAND FUNCTIONAL MEDICINE LLC
Entity type:Organization
Organization Name:ISLAND FUNCTIONAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KALIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUZUKI
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:808-352-1680
Mailing Address - Street 1:92-1535 ALIINUI DR # 6B
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-2223
Mailing Address - Country:US
Mailing Address - Phone:808-352-1680
Mailing Address - Fax:
Practice Address - Street 1:2176 LAUWILIWILI ST STE 12
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-1882
Practice Address - Country:US
Practice Address - Phone:808-465-3000
Practice Address - Fax:808-465-3574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-01
Last Update Date:2020-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care