Healthcare Provider Details

I. General information

NPI: 1912299264
Provider Name (Legal Business Name): CARLY M WATANABE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 07/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 ULUNIU ST #301
KAILUA HI
96734-2519
US

IV. Provider business mailing address

407 ULUNIU ST #301
KAILUA HI
96734-2519
US

V. Phone/Fax

Practice location:
  • Phone: 808-261-4321
  • Fax: 808-261-4320
Mailing address:
  • Phone: 808-261-4321
  • Fax: 808-261-4320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT3327
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: