1255495180 NPI number — MR. ERIC EDWARD ERSSON PT PHYSICAL THERAPIS

Table of content: MR. ERIC EDWARD ERSSON PT PHYSICAL THERAPIS (NPI 1255495180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255495180 NPI number — MR. ERIC EDWARD ERSSON PT PHYSICAL THERAPIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERSSON
Provider First Name:
ERIC
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT PHYSICAL THERAPIS
Provider Gender Code:
M

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:
1255495180
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
411 HUKU LII PL STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KIHEI
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96753-7062
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-298-4933
Provider Business Mailing Address Fax Number:
732-223-6409

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
IMUA PHYSICAL THERAPY
Provider Second Line Business Practice Location Address:
40 KUPAOA STREET B-201
Provider Business Practice Location Address City Name:
MAKAWAO
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-298-4933
Provider Business Practice Location Address Fax Number:
808-298-4933
Provider Enumeration Date:
12/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  QA04764 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 5683 , 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)





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