Provider Demographics
NPI:1821598699
Name:PROVENCIO, ANTONIO (LAC)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:PROVENCIO
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 1:98-199 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:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-17
Last Update Date:2018-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171100000X, 225700000X
HI171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1231OtherACUPUNCTURE STATE LICENSE
CA17178OtherACUPUNCTURE STATE LICENSE
1740780949OtherNPI FOR EAST 2 WEST INTEGRATIVE MEDICINE