Provider Demographics
NPI:1326235128
Name:MOON PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:MOON PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:S O
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:808-597-1005
Mailing Address - Street 1:320 WARD AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-4001
Mailing Address - Country:US
Mailing Address - Phone:808-597-1005
Mailing Address - Fax:808-597-1006
Practice Address - Street 1:320 WARD AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-4001
Practice Address - Country:US
Practice Address - Phone:808-597-1005
Practice Address - Fax:808-597-1006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT 1843225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI=========OtherFED TAX ID