Provider Demographics
NPI:1467580712
Name:EWA BEACH PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:EWA BEACH PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:H
Authorized Official - Last Name:TAKIGUCHI
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:808-689-9994
Mailing Address - Street 1:91-2139 FORT WEAVER RD
Mailing Address - Street 2:STE 210
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-3609
Mailing Address - Country:US
Mailing Address - Phone:808-689-9994
Mailing Address - Fax:808-689-9995
Practice Address - Street 1:91-2139 FORT WEAVER RD
Practice Address - Street 2:STE 210
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-3609
Practice Address - Country:US
Practice Address - Phone:808-689-9994
Practice Address - Fax:808-689-9995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1315261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy