Provider Demographics
NPI:1508314089
Name:JACO REHAB MILILANI LLC
Entity Type:Organization
Organization Name:JACO REHAB MILILANI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACO
Authorized Official - Middle Name:J
Authorized Official - Last Name:VAN DELDEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:808-381-8947
Mailing Address - Street 1:1401 S BERETANIA ST
Mailing Address - Street 2:SUITE 550
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-1870
Mailing Address - Country:US
Mailing Address - Phone:808-381-8947
Mailing Address - Fax:808-591-2245
Practice Address - Street 1:95-1105 AINAMAKUA DRIVE
Practice Address - Street 2:SUITE 203
Practice Address - City:MILILANI
Practice Address - State:HI
Practice Address - Zip Code:96789
Practice Address - Country:US
Practice Address - Phone:808-381-8947
Practice Address - Fax:808-591-2245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT-1582225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty