Healthcare Provider Details

I. General information

NPI: 1487125183
Provider Name (Legal Business Name): SIDNEY LEWIS LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2018
Last Update Date: 12/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 KAUHIKOA RD
HAIKU HI
96708
US

IV. Provider business mailing address

PO BOX 413
MAKAWAO HI
96768-0413
US

V. Phone/Fax

Practice location:
  • Phone: 808-769-7764
  • Fax:
Mailing address:
  • Phone: 808-769-7764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number14902
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: