=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770011991
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANE SHIROMA LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2017
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3329 KANAINA AVE. #304
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96815-9681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-838-9090
-----------------------------------------------------
Fax | 808-838-9090
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3329 KANAINA AVE APT 304
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96815-4217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-838-9090
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MAT-14324
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------