Basic Information
Provider Information | |||||||||
NPI: | 1770512048 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ELAM SPORTS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ELAM SPORTS OAHU | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1001 KAMOKILA BLVD | ||||||||
Address2: | SUITE 111 JCB | ||||||||
City: | KAPOLEI | ||||||||
State: | HI | ||||||||
PostalCode: | 967072014 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8086749595 | ||||||||
FaxNumber: | 8086749696 | ||||||||
Practice Location | |||||||||
Address1: | 425 KAMEHAMEHA HWY | ||||||||
Address2: | SUITE 2B | ||||||||
City: | PEARL CITY | ||||||||
State: | HI | ||||||||
PostalCode: | 967823238 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8086749595 | ||||||||
FaxNumber: | 8086749696 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2006 | ||||||||
LastUpdateDate: | 11/27/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ELAM | ||||||||
AuthorizedOfficialFirstName: | CHANDRA | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | COMPANY OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8086749595 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
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 | 50320201 | 05 | HI |   | MEDICAID | A218931 | 01 | HI | HMSA | OTHER |