Basic Information
Provider Information | |||||||||
NPI: | 1164500286 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ISLAND PHYSICAL THERAPY, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1314 S KING ST | ||||||||
Address2: | SUITE 1451 | ||||||||
City: | HONOLULU | ||||||||
State: | HI | ||||||||
PostalCode: | 968141956 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8085932610 | ||||||||
FaxNumber: | 8085919420 | ||||||||
Practice Location | |||||||||
Address1: | 1314 S KING ST | ||||||||
Address2: | SUITE 1451 | ||||||||
City: | HONOLULU | ||||||||
State: | HI | ||||||||
PostalCode: | 968141956 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8085932610 | ||||||||
FaxNumber: | 8085919420 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/02/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ISHIHARA | ||||||||
AuthorizedOfficialFirstName: | DERRICK | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 8085932610 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 250084 | 05 | HI |   | MEDICAID |