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General NPI Number Information
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NPI Number | 1316596778
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Entity Type | Individual
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Provider Name | VONTRESS MITCHELL
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Gender | Male
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Dates
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Enumeration Date | 09/09/2019
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Last Update Date | 09/09/2019
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Provider Practice Location Address
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Address Line | 1090 KEOLU DR STE 104
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City | KAILUA
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State | HI
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Zip | 96734-3871
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Country | US
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Telephone | 808-262-2292
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Fax |
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Provider Business Mailing Address
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Address Line | 111 HEKILI ST # A376
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City | KAILUA
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State | HI
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Zip | 96734-2800
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Country | US
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Telephone | 808-201-2020
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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 | MAT-15259
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License Number State | HI
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