Provider Demographics
NPI:1104475292
Name:GONSALVES, MANUEL
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:GONSALVES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1319 PUNAHOU ST STE 910
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96826-1088
Mailing Address - Country:US
Mailing Address - Phone:808-722-1443
Mailing Address - Fax:
Practice Address - Street 1:1319 PUNAHOU ST STE 910
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96826-1088
Practice Address - Country:US
Practice Address - Phone:808-722-1443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI16098225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist