Provider Demographics
NPI:1689651002
Name:ENRIQUEZ, MEYNARD VILLENAS (PT)
Entity Type:Individual
Prefix:
First Name:MEYNARD
Middle Name:VILLENAS
Last Name:ENRIQUEZ
Suffix:
Gender:M
Credentials:PT
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 288
Mailing Address - Street 2:
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-0288
Mailing Address - Country:US
Mailing Address - Phone:808-634-7055
Mailing Address - Fax:
Practice Address - Street 1:3088A AUKELE ST
Practice Address - Street 2:
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-1464
Practice Address - Country:US
Practice Address - Phone:808-632-0033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2583225100000X
CAPT 29450174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13096Medicare ID - Type UnspecifiedGROUP
HIBD075ZMedicare PIN