Provider Demographics
NPI:1912301250
Name:BOLANOS, BRENDA (LMT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:BOLANOS
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 356
Mailing Address - Street 2:
Mailing Address - City:LAHAINA
Mailing Address - State:HI
Mailing Address - Zip Code:96767-0356
Mailing Address - Country:US
Mailing Address - Phone:310-779-9680
Mailing Address - Fax:
Practice Address - Street 1:15 E KUU AKU LN UNIT 109
Practice Address - Street 2:
Practice Address - City:LAHAINA
Practice Address - State:HI
Practice Address - Zip Code:96761-2750
Practice Address - Country:US
Practice Address - Phone:310-779-9680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI13382171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor