Healthcare Provider Details

I. General information

NPI: 1174392617
Provider Name (Legal Business Name): CONSTANCIO G BUMANGLAG JR. PBT, ASCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2023
Last Update Date: 12/26/2023
Certification Date: 12/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 1001 KEAUNUI DRIVE 215
EWA BEACH HI
96706
US

IV. Provider business mailing address

91 1001 KEAUNUI DRIVE 215
EWA BEACH HI
96706
US

V. Phone/Fax

Practice location:
  • Phone: 808-393-8073
  • Fax: 808-517-5173
Mailing address:
  • Phone: 808-393-8073
  • Fax: 808-517-5173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number68986
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: