Provider Demographics
NPI:1003463373
Name:CACERES, BLAINE KK (LICENSED MASSAGE THE)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:KK
Last Name:CACERES
Suffix:
Gender:M
Credentials:LICENSED MASSAGE THE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 AWA ST
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-5809
Mailing Address - Country:US
Mailing Address - Phone:808-960-9941
Mailing Address - Fax:
Practice Address - Street 1:475 AWA ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-5809
Practice Address - Country:US
Practice Address - Phone:808-960-9941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI15734225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist