Provider Demographics
NPI:1164647418
Name:KIHEI-WAILEA PHYSICAL THERAPY INC.
Entity Type:Organization
Organization Name:KIHEI-WAILEA PHYSICAL THERAPY INC.
Other - Org Name:BACK IN SHAPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:808-879-5591
Mailing Address - Street 1:PO BOX 508
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-0508
Mailing Address - Country:US
Mailing Address - Phone:808-879-5591
Mailing Address - Fax:
Practice Address - Street 1:84 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-1725
Practice Address - Country:US
Practice Address - Phone:808-879-5591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI561261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000231639OtherHMSA
HI0000231639OtherHMSA