Provider Demographics
NPI:1740780949
Name:EAST 2 WEST INTEGRATIVE MEDICINE LLC
Entity Type:Organization
Organization Name:EAST 2 WEST INTEGRATIVE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVENCIO
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:808-364-1555
Mailing Address - Street 1:98-199 KAMEHAMEHA HWY STE F3
Mailing Address - Street 2:
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-4820
Mailing Address - Country:US
Mailing Address - Phone:808-364-1555
Mailing Address - Fax:844-771-9312
Practice Address - Street 1:98-199 KAMEHAMEHA HWY STE F3
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701
Practice Address - Country:US
Practice Address - Phone:808-364-1555
Practice Address - Fax:844-771-9312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-14
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty