Provider Demographics
NPI:1821844598
Name:WALLACE, MARTIN SCOTT (LMT)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:SCOTT
Last Name:WALLACE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68-3840 LUA KULA ST
Mailing Address - Street 2:ADMIN 3
Mailing Address - City:WAIKOLOA
Mailing Address - State:HI
Mailing Address - Zip Code:96738
Mailing Address - Country:US
Mailing Address - Phone:808-909-3111
Mailing Address - Fax:
Practice Address - Street 1:68-3840 LUA KULA ST
Practice Address - Street 2:ADMIN 3
Practice Address - City:WAIKOLOA
Practice Address - State:HI
Practice Address - Zip Code:96738
Practice Address - Country:US
Practice Address - Phone:808-909-3111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-16955225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist