Provider Demographics
NPI:1093011173
Name:CLOSE, PEGGY (PT)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:CLOSE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5044 KALANIANAOLE HWY
Mailing Address - Street 2:QUARTERS A
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96821-1563
Mailing Address - Country:US
Mailing Address - Phone:808-377-8486
Mailing Address - Fax:
Practice Address - Street 1:710 GREEN ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2119
Practice Address - Country:US
Practice Address - Phone:808-536-3764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI3243225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist