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General NPI Number Information
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NPI Number | 1205394913
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Entity Type | Individual
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Provider Name | GAWA KEALOHA TAM
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Gender | Female
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Dates
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Enumeration Date | 03/12/2019
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Last Update Date | 03/12/2019
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Provider Practice Location Address
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Address Line | 15-1925 14TH AVE
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City | KEAAU
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State | HI
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Zip | 96749-9674
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Country | US
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Telephone | 808-966-4747
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Fax |
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Provider Business Mailing Address
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Address Line | HC 3 BOX 11015
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City | KEAAU
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State | HI
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Zip | 96749-9205
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Country | US
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Telephone | 808-966-4747
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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 | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 11333
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License Number State | HI
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