Healthcare Provider Details

I. General information

NPI: 1508681768
Provider Name (Legal Business Name): LAUREL LABISTRE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2024
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 KEAWE ST STE 159B
HILO HI
96720-2824
US

IV. Provider business mailing address

LAUREL LABISTRE GENERAL DELIVERY
MOUNTAIN VIEW HI
96771
US

V. Phone/Fax

Practice location:
  • Phone: 808-785-7624
  • Fax:
Mailing address:
  • Phone: 808-785-7624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMAT-18018
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: