Basic Information
| Provider Information | |||||||||
| NPI: | 1629309331 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PAKOLEA LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BIG ISLAND PHYSICAL THERPAY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6783 | ||||||||
| Address2: | |||||||||
| City: | HILO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8089355255 | ||||||||
| FaxNumber: | 8089619044 | ||||||||
| Practice Location | |||||||||
| Address1: | 740 KILAUEA AVENUE | ||||||||
| Address2: | |||||||||
| City: | HILO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8089355255 | ||||||||
| FaxNumber: | 8089619044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2010 | ||||||||
| LastUpdateDate: | 03/03/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WAIKI | ||||||||
| AuthorizedOfficialFirstName: | SHAUNA | ||||||||
| AuthorizedOfficialMiddleName: | KAIULANI RUSSELL | ||||||||
| AuthorizedOfficialTitleorPosition: | CO-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8089355255 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT-3052 | HI | N | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 261QR0400X | PT-3052 | HI | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.