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General NPI Number Information
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NPI Number | 1053930784
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Entity Type | Individual
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Provider Name | MARI KONG ATC
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Gender | Female
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Dates
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Enumeration Date | 04/13/2020
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Last Update Date | 04/13/2020
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Provider Practice Location Address
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Address Line | 1564 N KING ST
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City | HONOLULU
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State | HI
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Zip | 96817-4229
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Country | US
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Telephone | 808-255-9690
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Fax |
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Provider Business Mailing Address
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Address Line | 94-1041 KOLIANA ST
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City | WAIPAHU
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State | HI
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Zip | 96797-4310
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT-65
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License Number State | HI
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