Provider Demographics
NPI:1336608926
Name:FOLSOM, ILLAH (LMT)
Entity Type:Individual
Prefix:
First Name:ILLAH
Middle Name:
Last Name:FOLSOM
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:PO BOX 361
Mailing Address - Street 2:
Mailing Address - City:KULA
Mailing Address - State:HI
Mailing Address - Zip Code:96790-0361
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5281 LOWER KULA RD
Practice Address - Street 2:
Practice Address - City:KULA
Practice Address - State:HI
Practice Address - Zip Code:96790-7712
Practice Address - Country:US
Practice Address - Phone:808-269-2972
Practice Address - Fax:808-878-1879
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-15920225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIMAT-15920OtherMASSAGE LICENSE