Healthcare Provider Details

I. General information

NPI: 1649509886
Provider Name (Legal Business Name): LEIGH K KUPO LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: LEE K KUPO LMT

II. Dates (important events)

Enumeration Date: 12/17/2009
Last Update Date: 12/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 CENTRAL AVE
WAILUKU HI
96793-1723
US

IV. Provider business mailing address

PO BOX 6062
KAHULUI HI
96733-6062
US

V. Phone/Fax

Practice location:
  • Phone: 808-269-2154
  • Fax:
Mailing address:
  • Phone: 808-269-2154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMAT 7829
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: