Provider Demographics
NPI:1679865505
Name:PEPPER, TARA (MS, PT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:PEPPER
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2061 S KIHEI RD
Mailing Address - Street 2:APT 2
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-9702
Mailing Address - Country:US
Mailing Address - Phone:720-206-5931
Mailing Address - Fax:
Practice Address - Street 1:472 KAULANA ST
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-2050
Practice Address - Country:US
Practice Address - Phone:808-877-2761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI4214225100000X
CO7485225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist