Healthcare Provider Details

I. General information

NPI: 1588899298
Provider Name (Legal Business Name): MATI SAPOLU MASSAGE THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2009
Last Update Date: 05/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1019 UNIVERSITY AVE SUITE T02
HONOLULU HI
96826-1509
US

IV. Provider business mailing address

1019 UNIVERSITY AVENUE SUITE T02
HONOLULU HI
96826
US

V. Phone/Fax

Practice location:
  • Phone: 808-203-0776
  • Fax:
Mailing address:
  • Phone: 808-203-0776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberLMT8600
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: