Provider Demographics
NPI:1376183756
Name:GOLDFARB, JAMES BLAKE (MT)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:BLAKE
Last Name:GOLDFARB
Suffix:
Gender:M
Credentials:MT
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 1576
Mailing Address - Street 2:
Mailing Address - City:PAHOA
Mailing Address - State:HI
Mailing Address - Zip Code:96778-1576
Mailing Address - Country:US
Mailing Address - Phone:808-464-3311
Mailing Address - Fax:
Practice Address - Street 1:120 KEAWE ST STE 204D
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2874
Practice Address - Country:US
Practice Address - Phone:808-464-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI15952225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist