Provider Demographics
NPI:1558025650
Name:VITITOW, MYRON JAMES (LMT)
Entity Type:Individual
Prefix:
First Name:MYRON
Middle Name:JAMES
Last Name:VITITOW
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 1:68-677 FARRINGTON HWY
Mailing Address - Street 2:
Mailing Address - City:WAIALUA
Mailing Address - State:HI
Mailing Address - Zip Code:96791-9355
Mailing Address - Country:US
Mailing Address - Phone:518-818-4469
Mailing Address - Fax:
Practice Address - Street 1:68-139 AU ST
Practice Address - Street 2:
Practice Address - City:WAIALUA
Practice Address - State:HI
Practice Address - Zip Code:96791-8405
Practice Address - Country:US
Practice Address - Phone:518-344-0396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-167775225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist