1336649433 NPI number — SOUTH KONA PHYSICAL THERAPY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336649433 NPI number — SOUTH KONA PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH KONA PHYSICAL THERAPY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336649433
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
82-6066 MAMALAHOA HWY STE 7
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPTAIN COOK
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96704-8204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-323-8123
Provider Business Mailing Address Fax Number:
808-323-8125

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
82-6066 MAMALAHOA HWY
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
CAPTAIN COOK
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-323-8123
Provider Business Practice Location Address Fax Number:
808-323-8125
Provider Enumeration Date:
02/15/2018

Additional Information

Authorized Official

Authorized Official Last Name:
FACKLER
Authorized Official First Name:
BETTY
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
808-896-7527

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  HI1737 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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