Provider Demographics
NPI:1376959650
Name:PHYSICAL & INDUSTRIAL REHABILITATION CLINIC OF OAHU LLC
Entity Type:Organization
Organization Name:PHYSICAL & INDUSTRIAL REHABILITATION CLINIC OF OAHU LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MIZOGUCHI
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:808-524-5247
Mailing Address - Street 1:1221 KAPIOLANI BLVD
Mailing Address - Street 2:STE 820
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-3503
Mailing Address - Country:US
Mailing Address - Phone:808-524-5247
Mailing Address - Fax:808-440-5251
Practice Address - Street 1:2810 PAA ST
Practice Address - Street 2:BUILDING A
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-4429
Practice Address - Country:US
Practice Address - Phone:808-524-5247
Practice Address - Fax:808-440-5251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
HIOT151225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty