Provider Demographics
NPI:1467947887
Name:FABREGAS, BLOSSOM
Entity Type:Individual
Prefix:
First Name:BLOSSOM
Middle Name:
Last Name:FABREGAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 MAKALANI PL
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-8909
Mailing Address - Country:US
Mailing Address - Phone:808-372-9520
Mailing Address - Fax:
Practice Address - Street 1:67 MAKALANI PL
Practice Address - Street 2:
Practice Address - City:MAKAWAO
Practice Address - State:HI
Practice Address - Zip Code:96768-8909
Practice Address - Country:US
Practice Address - Phone:808-372-9520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT11913225700000X
HI11913225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist