Healthcare Provider Details

I. General information

NPI: 1073128633
Provider Name (Legal Business Name): MARK GUPPY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2020
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
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

64-648 PUU POHU PL
KAMUELA HI
96743-8139
US

V. Phone/Fax

Practice location:
  • Phone: 808-937-0069
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: