Provider Demographics
NPI:1598215618
Name:CORK, BRIAN (LAC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:CORK
Suffix:
Gender:M
Credentials:LAC
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 31
Mailing Address - Street 2:
Mailing Address - City:HALEIWA
Mailing Address - State:HI
Mailing Address - Zip Code:96712-0031
Mailing Address - Country:US
Mailing Address - Phone:808-343-2024
Mailing Address - Fax:
Practice Address - Street 1:66-590 KAMEHAMEHA HWY
Practice Address - Street 2:
Practice Address - City:HALEIWA
Practice Address - State:HI
Practice Address - Zip Code:96712-2402
Practice Address - Country:US
Practice Address - Phone:808-343-2024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI973171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist