Healthcare Provider Details

I. General information

NPI: 1003306614
Provider Name (Legal Business Name): TRACY NEIL TAKEMOTO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2-2527 KAUMUALII HWY
KALAHEO HI
96741-8309
US

IV. Provider business mailing address

PO BOX 945
HANAPEPE HI
96716-0945
US

V. Phone/Fax

Practice location:
  • Phone: 808-332-5580
  • Fax:
Mailing address:
  • Phone: 808-217-5010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number15154
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: