Healthcare Provider Details

I. General information

NPI: 1326425083
Provider Name (Legal Business Name): LAUREN DEWEESE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2015
Last Update Date: 05/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76-6194 HOLUALOA BEACH RD UNIT 6
KAILUA-KONA HI
96740
US

IV. Provider business mailing address

PO BOX 5529
KAILUA KONA HI
96745-5529
US

V. Phone/Fax

Practice location:
  • Phone: 808-238-2503
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMAT-14006
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: