Provider Demographics
NPI:1346442324
Name:PHYSICAL THERAPY HOMECARE
Entity Type:Organization
Organization Name:PHYSICAL THERAPY HOMECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER LLC, PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:PROBERT
Authorized Official - Last Name:ELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:808-250-6260
Mailing Address - Street 1:PO BOX 6359
Mailing Address - Street 2:
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96733-6359
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 KEONEKAI RD
Practice Address - Street 2:
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-7123
Practice Address - Country:US
Practice Address - Phone:808-250-6260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-02
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1859225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI100494Medicare PIN