=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861801904
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. JOETTE BLACK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2014
-----------------------------------------------------
Last Update Date | 08/02/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2260 KANAKANUI RD
-----------------------------------------------------
City | KIHEI
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96753-8557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-276-6335
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2260 KANAKANUI RD
-----------------------------------------------------
City | KIHEI
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96753-8557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-276-6335
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 173C00000X
-----------------------------------------------------
Taxonomy Name | Reflexologist
-----------------------------------------------------
License Number | MAT-6040
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------