Provider Demographics
NPI:1801237045
Name:GREEN TI BOUTIQUE AND MASSAGE LLC
Entity type:Organization
Organization Name:GREEN TI BOUTIQUE AND MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:OLEKSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-242-8788
Mailing Address - Street 1:40 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1718
Mailing Address - Country:US
Mailing Address - Phone:808-242-8788
Mailing Address - Fax:808-242-8788
Practice Address - Street 1:40 N MARKET ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1718
Practice Address - Country:US
Practice Address - Phone:808-242-8788
Practice Address - Fax:808-242-8788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2281225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty