Provider Demographics
NPI:1336513332
Name:BARTOLOME, MARK (LMT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:BARTOLOME
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 1:929 SHERIDAN ST APT 209
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-5401
Mailing Address - Country:US
Mailing Address - Phone:808-354-9866
Mailing Address - Fax:
Practice Address - Street 1:929 SHERIDAN ST APT 209
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-5401
Practice Address - Country:US
Practice Address - Phone:808-354-9866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-14
Last Update Date:2015-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-13238225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist