Provider Demographics
NPI:1124187786
Name:COUNTRYSIDE PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:COUNTRYSIDE PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIKUCHI
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:808-637-4010
Mailing Address - Street 1:67-188 KUHI ST
Mailing Address - Street 2:
Mailing Address - City:WAIALUA
Mailing Address - State:HI
Mailing Address - Zip Code:96791-9634
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:67-292 GOODALE AVE #A4
Practice Address - Street 2:
Practice Address - City:WAIALUA
Practice Address - State:HI
Practice Address - Zip Code:96791
Practice Address - Country:US
Practice Address - Phone:808-637-4010
Practice Address - Fax:808-637-6020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT-2333225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI258921OtherHMSA
HI2058706OtherUNIVERSITY HEALTH ALLIANC
HI540856OtherHMA, INC. HAWAII
HI578461Medicaid
HI57847900OtherALOHACARE
HI57847900OtherALOHACARE
HI101417Medicare ID - Type Unspecified