Healthcare Provider Details

I. General information

NPI: 1558808576
Provider Name (Legal Business Name): BEVERLY GRANDE KOKI MASSAGE THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2017
Last Update Date: 01/28/2017
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 150
ELEELE HI
96705-0150
US

V. Phone/Fax

Practice location:
  • Phone: 808-332-5580
  • Fax:
Mailing address:
  • Phone: 808-346-8070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number14850
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: