Healthcare Provider Details

I. General information

NPI: 1952738726
Provider Name (Legal Business Name): DONNA BARRACA ROLDAN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2013
Last Update Date: 10/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94-366 PUPUPANI STREET SUITE 209B
WAIPAHU HI
96797
US

IV. Provider business mailing address

94-366 PUPUPANI STREET SUITE 209B
WAIPAHU HI
96797
US

V. Phone/Fax

Practice location:
  • Phone: 808-597-6103
  • Fax: 808-680-0015
Mailing address:
  • Phone: 808-597-6103
  • Fax: 808-680-0015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number12108
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: