Healthcare Provider Details

I. General information

NPI: 1760426944
Provider Name (Legal Business Name): CHASE KEN MITSUDA ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2445 KAALA STREET MID PACIFIC INSTITUTE
HONOLULU HI
96822-2299
US

IV. Provider business mailing address

45-697 KAMEHAMEHA HWY APT # 207
KANEOHE HI
96744-2053
US

V. Phone/Fax

Practice location:
  • Phone: 808-973-5091
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: