Healthcare Provider Details

I. General information

NPI: 1467538066
Provider Name (Legal Business Name): CARRIE C HISATOMI LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 MAKAWAO AVE STE 101
MAKAWAO HI
96768-7401
US

IV. Provider business mailing address

PO BOX 127
MAKAWAO HI
96768-0127
US

V. Phone/Fax

Practice location:
  • Phone: 808-268-8460
  • Fax:
Mailing address:
  • Phone: 808-268-8460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberACU874
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: