Healthcare Provider Details

I. General information

NPI: 1225220189
Provider Name (Legal Business Name): LISA MARY DOREEN ORTIZ LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 08/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54-316 KAMEHAMEHA HWY SUITE 7
HAUULA HI
96717-9539
US

IV. Provider business mailing address

PO BOX 1875
AIEA HI
96701-7875
US

V. Phone/Fax

Practice location:
  • Phone: 808-293-5377
  • Fax: 808-293-5390
Mailing address:
  • Phone: 808-306-0081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number6174
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: