Provider Demographics
NPI:1457455479
Name:RIETFORS, JUSTIN A (DPT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:A
Last Name:RIETFORS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1440
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-1440
Mailing Address - Country:US
Mailing Address - Phone:808-262-2292
Mailing Address - Fax:808-262-2293
Practice Address - Street 1:1090 KEOLU DR STE 104
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-3871
Practice Address - Country:US
Practice Address - Phone:808-262-2292
Practice Address - Fax:808-262-2293
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT2543225100000X
HI2543225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist