Healthcare Provider Details

I. General information

NPI: 1558519801
Provider Name (Legal Business Name): KIMBERLY MARIE LAATSCH L.M.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 08/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75-5929 ALII DR
KAILUA KONA HI
96740-1323
US

IV. Provider business mailing address

PO BOX 391180
KEAUHOU HI
96739-1180
US

V. Phone/Fax

Practice location:
  • Phone: 808-640-0505
  • Fax:
Mailing address:
  • Phone: 808-640-0505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMAT 7334
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: