Provider Demographics
NPI:1093279002
Name:MEDINA, CAROLINA LEILANI (LMT)
Entity Type:Individual
Prefix:
First Name:CAROLINA
Middle Name:LEILANI
Last Name:MEDINA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:CAROLINA
Other - Middle Name:LEILANI
Other - Last Name:MEDINA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:PO BOX 4296
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96745-4296
Mailing Address - Country:US
Mailing Address - Phone:808-315-2628
Mailing Address - Fax:
Practice Address - Street 1:75-5759 KUAKINI HWY
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-1726
Practice Address - Country:US
Practice Address - Phone:808-327-9791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI15441225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty