Provider Demographics
NPI:1548485808
Name:BELLERUE, ILENE MARTINO (LAC)
Entity type:Individual
Prefix:
First Name:ILENE
Middle Name:MARTINO
Last Name:BELLERUE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 ULANA ST
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-8034
Mailing Address - Country:US
Mailing Address - Phone:808-573-7770
Mailing Address - Fax:808-573-7770
Practice Address - Street 1:205 ULANA ST
Practice Address - Street 2:
Practice Address - City:MAKAWAO
Practice Address - State:HI
Practice Address - Zip Code:96768-8034
Practice Address - Country:US
Practice Address - Phone:808-573-7770
Practice Address - Fax:808-573-7770
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIACU-382171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist