Provider Demographics
NPI:1366100141
Name:PALISOC, MARC DAVID REYES
Entity type:Individual
Prefix:
First Name:MARC DAVID
Middle Name:REYES
Last Name:PALISOC
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 1:99-015 KALALOA ST APT 301
Mailing Address - Street 2:
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-3830
Mailing Address - Country:US
Mailing Address - Phone:808-227-8265
Mailing Address - Fax:
Practice Address - Street 1:99-015 KALALOA ST APT 301
Practice Address - Street 2:
Practice Address - City:AIEA
Practice Address - State:HI
Practice Address - Zip Code:96701-3830
Practice Address - Country:US
Practice Address - Phone:808-227-8265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI349TXG343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)