Provider Demographics
NPI:1235297151
Name:WATERFRONT PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:WATERFRONT PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALYCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-593-4005
Mailing Address - Street 1:PO BOX 15683
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96830-5683
Mailing Address - Country:US
Mailing Address - Phone:808-593-4005
Mailing Address - Fax:808-591-2625
Practice Address - Street 1:1221 KAPIOLANI BLVD
Practice Address - Street 2:6 G
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814
Practice Address - Country:US
Practice Address - Phone:808-593-4005
Practice Address - Fax:808-591-2625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT 1990225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000232694OtherHMSA
HI55395Medicare ID - Type Unspecified
HI54496701Medicare ID - Type Unspecified