Provider Demographics
NPI:1164954012
Name:MIJARES, RYAN TUCKER (DC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:TUCKER
Last Name:MIJARES
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 953
Mailing Address - Street 2:
Mailing Address - City:KILAUEA
Mailing Address - State:HI
Mailing Address - Zip Code:96754-0953
Mailing Address - Country:US
Mailing Address - Phone:808-631-2508
Mailing Address - Fax:
Practice Address - Street 1:5-5080 KUHIO HWY
Practice Address - Street 2:SUITE A
Practice Address - City:HANALEI
Practice Address - State:HI
Practice Address - Zip Code:96714
Practice Address - Country:US
Practice Address - Phone:808-631-2508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-30
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDC1365111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor