Provider Demographics
NPI:1205618113
Name:SUPREME WELLNESS
Entity type:Organization
Organization Name:SUPREME WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATSUMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-294-2632
Mailing Address - Street 1:665 HALEKAUWILA ST APT 2004
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-5914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 WAIMANU ST # D
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-3411
Practice Address - Country:US
Practice Address - Phone:808-294-2632
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-16
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty