Provider Demographics
NPI:1013338516
Name:MOGHADAM, MINA (LMT)
Entity Type:Individual
Prefix:MS
First Name:MINA
Middle Name:
Last Name:MOGHADAM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 KENUI CIR
Mailing Address - Street 2:
Mailing Address - City:LAHAINA
Mailing Address - State:HI
Mailing Address - Zip Code:96761-2354
Mailing Address - Country:US
Mailing Address - Phone:808-205-7751
Mailing Address - Fax:
Practice Address - Street 1:845 WAINEE ST
Practice Address - Street 2:SUITE 211
Practice Address - City:LAHAINA
Practice Address - State:HI
Practice Address - Zip Code:96761-2321
Practice Address - Country:US
Practice Address - Phone:808-667-1801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI13506174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist