Basic Information
| Provider Information | |||||||||
| NPI: | 1063746196 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JACO VAN DELDEN PHYSICAL REHABILITATION LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 S BERETANIA ST STE 550 | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968141880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083818947 | ||||||||
| FaxNumber: | 8085912245 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 S BERETANIA ST STE 550 | ||||||||
| Address2: | |||||||||
| City: | HONOLULU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 968141880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083818947 | ||||||||
| FaxNumber: | 8085912245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2009 | ||||||||
| LastUpdateDate: | 11/07/2019 | ||||||||
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| AuthorizedOfficialLastName: | VAN DELDEN | ||||||||
| AuthorizedOfficialFirstName: | JACO | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8083818947 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT-1582 | HI | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | A20852-8 | 01 | HI | HMSA | OTHER |