Provider Demographics
NPI:1093003246
Name:TAKEBAYASHI, KEN (LMT)
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:TAKEBAYASHI
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 ALANI DR
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96822-1415
Mailing Address - Country:US
Mailing Address - Phone:808-741-2201
Mailing Address - Fax:
Practice Address - Street 1:725 KAPIOLANI BLVD STE C202
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-6023
Practice Address - Country:US
Practice Address - Phone:808-596-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-12302225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist