Provider Demographics
NPI:1164500286
Name:ISLAND PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:ISLAND PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:K
Authorized Official - Last Name:ISHIHARA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:808-593-2610
Mailing Address - Street 1:1314 S KING ST
Mailing Address - Street 2:SUITE 1451
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-1956
Mailing Address - Country:US
Mailing Address - Phone:808-593-2610
Mailing Address - Fax:808-591-9420
Practice Address - Street 1:1314 S KING ST
Practice Address - Street 2:SUITE 1451
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-1956
Practice Address - Country:US
Practice Address - Phone:808-593-2610
Practice Address - Fax:808-591-9420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI250084Medicaid
HI250084Medicaid