Provider Demographics
NPI:1760435218
Name:SOUTH SHORE PHYSICAL THERAPY & SPORTSMEDICINE, INC
Entity Type:Organization
Organization Name:SOUTH SHORE PHYSICAL THERAPY & SPORTSMEDICINE, INC
Other - Org Name:IMUA PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRES
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:G
Authorized Official - Last Name:PRANGNELL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:808-879-0077
Mailing Address - Street 1:411 HUKU LII PL,. STE 101
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753
Mailing Address - Country:US
Mailing Address - Phone:808-879-0077
Mailing Address - Fax:808-879-0177
Practice Address - Street 1:411 HUKU LII PL STE 101
Practice Address - Street 2:
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753
Practice Address - Country:US
Practice Address - Phone:808-298-4933
Practice Address - Fax:808-879-0177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty