Healthcare Provider Details

I. General information

NPI: 1467000323
Provider Name (Legal Business Name): HILO BACK AND NECK PAIN CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2019
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 PONAHAWAI ST
HILO HI
96720-3004
US

IV. Provider business mailing address

118 PONAHAWAI ST
HILO HI
96720-3004
US

V. Phone/Fax

Practice location:
  • Phone: 808-464-5195
  • Fax:
Mailing address:
  • Phone: 808-464-5195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE WONG
Title or Position: MASSAGE THERAPIST
Credential: MAT9178
Phone: 808-741-1242