Provider Demographics
NPI:1962112409
Name:BALDONADO-KALEIOPU, TYERELL
Entity type:Individual
Prefix:
First Name:TYERELL
Middle Name:
Last Name:BALDONADO-KALEIOPU
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 1:930 EHOEHO ST
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-9710
Mailing Address - Country:US
Mailing Address - Phone:808-344-6869
Mailing Address - Fax:
Practice Address - Street 1:2045 MAIN ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1648
Practice Address - Country:US
Practice Address - Phone:808-242-8844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-23
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI17175225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist