Healthcare Provider Details

I. General information

NPI: 1750658118
Provider Name (Legal Business Name): LUKE KUSUMOTO LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2011
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 GREEN ST
HONOLULU HI
96813-2119
US

IV. Provider business mailing address

1950 UMALU PL
HONOLULU HI
96819-3056
US

V. Phone/Fax

Practice location:
  • Phone: 808-536-3764
  • Fax: 808-521-4491
Mailing address:
  • Phone: 808-845-4774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLSW-1718
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: