Provider Demographics
NPI:1821787409
Name:INTONG, KIRK RUBINSON JUMALON
Entity Type:Individual
Prefix:
First Name:KIRK RUBINSON
Middle Name:JUMALON
Last Name:INTONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-750 ONEULA PL
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-2552
Mailing Address - Country:US
Mailing Address - Phone:808-393-4919
Mailing Address - Fax:
Practice Address - Street 1:91-750 ONEULA PL
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-2552
Practice Address - Country:US
Practice Address - Phone:808-393-4919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIH01275024172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver