Healthcare Provider Details

I. General information

NPI: 1063317121
Provider Name (Legal Business Name): SANDRA RODRIGUEZ MAT 16657
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 LUNA LANE UNIT 1B
PAIA HI
96779
US

IV. Provider business mailing address

PO BOX 901447
KULA HI
96790-1447
US

V. Phone/Fax

Practice location:
  • Phone: 808-463-1709
  • Fax:
Mailing address:
  • Phone: 808-463-1709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number16657
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: