Provider Demographics
NPI:1790881738
Name:NORTH SHORE PYSICAL THERAPY & SPORTS REHAB LLC
Entity Type:Organization
Organization Name:NORTH SHORE PYSICAL THERAPY & SPORTS REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT
Authorized Official - Prefix:
Authorized Official - First Name:ALFRED
Authorized Official - Middle Name:S
Authorized Official - Last Name:LOSBANOS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:808-293-9885
Mailing Address - Street 1:56-565 KAMEHAMEHA HWY
Mailing Address - Street 2:
Mailing Address - City:KAHUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96731-2202
Mailing Address - Country:US
Mailing Address - Phone:808-293-9885
Mailing Address - Fax:808-293-1999
Practice Address - Street 1:56-565 KAMEHAMEHA HWY
Practice Address - Street 2:
Practice Address - City:KAHUKU
Practice Address - State:HI
Practice Address - Zip Code:96731-2202
Practice Address - Country:US
Practice Address - Phone:808-293-9885
Practice Address - Fax:808-293-1999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT 1401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH57168Medicare ID - Type Unspecified