Provider Demographics
NPI:1245700426
Name:SEBOURN, MARVIN DOUGLAS
Entity type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:DOUGLAS
Last Name:SEBOURN
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 1:596 KAAE RD
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1302
Mailing Address - Country:US
Mailing Address - Phone:808-264-6388
Mailing Address - Fax:
Practice Address - Street 1:95 LONO AVE
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-1610
Practice Address - Country:US
Practice Address - Phone:808-873-0733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI15310225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist