Provider Demographics
NPI:1265587315
Name:LEIALOHA LANE, JENNIFER KEI KEHAULANI (MSTOM, HHP, L AC)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:KEI KEHAULANI
Last Name:LEIALOHA LANE
Suffix:
Gender:F
Credentials:MSTOM, HHP, L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POST OFFICE BOX 9274
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546
Mailing Address - Country:US
Mailing Address - Phone:760-934-9659
Mailing Address - Fax:
Practice Address - Street 1:452 OLD MAMMOTH ROAD
Practice Address - Street 2:
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546
Practice Address - Country:US
Practice Address - Phone:760-934-7438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 11205171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist