Provider Demographics
NPI:1275737520
Name:COLLEN, GLEN ANDREW (LMT5268 LAC GC579)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:ANDREW
Last Name:COLLEN
Suffix:
Gender:M
Credentials:LMT5268 LAC GC579
Other - Prefix:
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Mailing Address - Street 1:449 KAILUA RD
Mailing Address - Street 2:C3
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734
Mailing Address - Country:US
Mailing Address - Phone:808-261-1024
Mailing Address - Fax:
Practice Address - Street 1:1051 KEOLU DR
Practice Address - Street 2:ENCHANTED LAKES MASSAGE CLINIC SUITE 104
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734
Practice Address - Country:US
Practice Address - Phone:808-262-6563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI579LAC171100000X
HILMT5268225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered171100000XOther Service ProvidersAcupuncturist
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist