1124187786 NPI number — COUNTRYSIDE PHYSICAL THERAPY, INC.

Table of content: (NPI 1124187786)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124187786 NPI number — COUNTRYSIDE PHYSICAL THERAPY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTRYSIDE PHYSICAL THERAPY, INC.
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:
1124187786
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
67-188 KUHI ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAIALUA
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96791-9634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
67-292 GOODALE AVE #A4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAIALUA
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96791
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-637-4010
Provider Business Practice Location Address Fax Number:
808-637-6020
Provider Enumeration Date:
12/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KIKUCHI
Authorized Official First Name:
KYLE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
808-637-4010

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT-2333 , 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)

  • Identifier: 258921 . This is a "HMSA" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 2058706 . This is a "UNIVERSITY HEALTH ALLIANC" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 540856 . This is a "HMA, INC. HAWAII" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".
  • Identifier: 578461 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57847900 . This is a "ALOHACARE" identifier , issued by the state of ( HI ) . This identifiers is of the category "OTHER".




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