Provider Demographics
NPI:1992165112
Name:VANT GROENEWOUT, KIMBERLY MIKLAS (LMT)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MIKLAS
Last Name:VANT GROENEWOUT
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 1:29 KAWEO PL
Mailing Address - Street 2:
Mailing Address - City:KULA
Mailing Address - State:HI
Mailing Address - Zip Code:96790-7939
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29 KAWEO PL
Practice Address - Street 2:
Practice Address - City:KULA
Practice Address - State:HI
Practice Address - Zip Code:96790-7939
Practice Address - Country:US
Practice Address - Phone:808-283-9194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-3885225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist