=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932585072
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BACK & BODY CLINIC OF HI, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2015
-----------------------------------------------------
Last Update Date | 07/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 81 CENTRAL AVENUE
-----------------------------------------------------
City | WAILUKU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-269-6419
-----------------------------------------------------
Fax | 808-633-4028
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 3073
-----------------------------------------------------
City | WAILUKU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-269-6419
-----------------------------------------------------
Fax | 808-633-4028
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. JEAN M. DAUNHAUER
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 808-269-6419
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------