Healthcare Provider Details

I. General information

NPI: 1609099415
Provider Name (Legal Business Name): JUANA MOYA LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78-7006 WAILUA RD
KAILUA-KONA HI
96740
US

IV. Provider business mailing address

77-6425 KUAKINI HWY SUITE C-2, #64
KAILUA KONA HI
96740-3213
US

V. Phone/Fax

Practice location:
  • Phone: 808-322-6871
  • Fax:
Mailing address:
  • Phone: 808-322-6871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number8947
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: