Provider Demographics
NPI:1639380264
Name:THERAPEUTIC ASSOCIATES OF MAUI, LLC
Entity Type:Organization
Organization Name:THERAPEUTIC ASSOCIATES OF MAUI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:MIZOGUCHI
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:808-877-8717
Mailing Address - Street 1:111 HANA HWY
Mailing Address - Street 2:SUITE 107
Mailing Address - City:KAHULUI
Mailing Address - State:HI
Mailing Address - Zip Code:96732-2300
Mailing Address - Country:US
Mailing Address - Phone:808-877-8717
Mailing Address - Fax:808-877-8718
Practice Address - Street 1:111 HANA HWY
Practice Address - Street 2:SUITE 107
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-2300
Practice Address - Country:US
Practice Address - Phone:808-877-8717
Practice Address - Fax:808-877-8718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI5289650001Medicare NSC
HIH54991Medicare PIN