Healthcare Provider Details

I. General information

NPI: 1649487828
Provider Name (Legal Business Name): TRACEYLIN SALES CROUCH MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 KALAEPAA DR
HONOLULU HI
96819-3010
US

IV. Provider business mailing address

1615 KALAEPAA DR
HONOLULU HI
96819-3010
US

V. Phone/Fax

Practice location:
  • Phone: 808-990-2060
  • Fax:
Mailing address:
  • Phone: 808-990-2060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT1390
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPTL0010328
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: