Healthcare Provider Details

I. General information

NPI: 1972947190
Provider Name (Legal Business Name): BRENDA KAY MACON LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 04/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95-720 LANIKUHANA AVE STE 140
MILILANI HI
96789-2985
US

IV. Provider business mailing address

95-720 LANIKUHANA AVE STE 140
MILILANI HI
96789-2985
US

V. Phone/Fax

Practice location:
  • Phone: 808-623-6244
  • Fax: 808-623-6414
Mailing address:
  • Phone: 808-623-6244
  • Fax: 808-623-6414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60113271
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLMT 14391
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: