Provider Demographics
NPI:1831902832
Name:WELLS, CORY IKAIKA (LMT)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:IKAIKA
Last Name:WELLS
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 1:732 POMAIKAI ST
Mailing Address - Street 2:
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96732-2543
Mailing Address - Country:US
Mailing Address - Phone:808-357-7912
Mailing Address - Fax:
Practice Address - Street 1:1975 E VINEYARD ST STE 403
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1728
Practice Address - Country:US
Practice Address - Phone:808-357-7912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-31
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-17949225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist