Provider Demographics
NPI:1912613530
Name:ILAGAN, MARK (LMT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ILAGAN
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 1:775 MCNEILL ST APT 118B
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-4218
Mailing Address - Country:US
Mailing Address - Phone:808-358-5751
Mailing Address - Fax:
Practice Address - Street 1:2024 N KING ST STE 109
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-3470
Practice Address - Country:US
Practice Address - Phone:808-847-2644
Practice Address - Fax:808-847-2624
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI10320225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist