Healthcare Provider Details

I. General information

NPI: 1093159840
Provider Name (Legal Business Name): RODOLFO SAGAYADORO GUMTANG JR. LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 04/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 MAA ST
KAHULUI HI
96732-3603
US

IV. Provider business mailing address

161 MAA ST
KAHULUI HI
96732-3603
US

V. Phone/Fax

Practice location:
  • Phone: 808-270-1893
  • Fax: 808-270-1892
Mailing address:
  • Phone: 808-270-1893
  • Fax: 808-270-1892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMAT-8942
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: