Provider Demographics
NPI:1558684084
Name:DE CALISTO, CAROLINA A
Entity Type:Individual
Prefix:
First Name:CAROLINA
Middle Name:A
Last Name:DE CALISTO
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 1:15 KULANIHAKOI ST APT 10C
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-7342
Mailing Address - Country:US
Mailing Address - Phone:808-280-1523
Mailing Address - Fax:
Practice Address - Street 1:1847 S KIHEI RD STE 104
Practice Address - Street 2:
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-7939
Practice Address - Country:US
Practice Address - Phone:808-280-1523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI8617225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist