Healthcare Provider Details

I. General information

NPI: 1639303779
Provider Name (Legal Business Name): ELYSE MARIE SURETTE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2009
Last Update Date: 05/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65-1230 MAMALAHOA HWY STE E11
KAMUELA HI
96743-7301
US

IV. Provider business mailing address

65-1230 MAMALAHOA HWY STE E11
KAMUELA HI
96743-7301
US

V. Phone/Fax

Practice location:
  • Phone: 808-885-7131
  • Fax: 808-885-5926
Mailing address:
  • Phone: 808-885-7131
  • Fax: 808-885-5926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2954
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: