Provider Demographics
NPI:1275964751
Name:ANGIE PETERS MPT LLC
Entity Type:Organization
Organization Name:ANGIE PETERS MPT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:808-280-7711
Mailing Address - Street 1:PO BOX 790826
Mailing Address - Street 2:
Mailing Address - City:PAIA
Mailing Address - State:HI
Mailing Address - Zip Code:96779-0826
Mailing Address - Country:US
Mailing Address - Phone:808-280-7711
Mailing Address - Fax:808-249-8650
Practice Address - Street 1:135 S WAKEA AVE
Practice Address - Street 2:UNIT 112
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-1385
Practice Address - Country:US
Practice Address - Phone:808-280-7711
Practice Address - Fax:808-442-0690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-09
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2575174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1093766610OtherUNSURE