Provider Demographics
NPI:1891724175
Name:PERFORMANCE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:PERFORMANCE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR OF PHYSICAL THERAPY
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:PAHANG
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, LMT
Authorized Official - Phone:808-308-5465
Mailing Address - Street 1:PO BOX 970116
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-0116
Mailing Address - Country:US
Mailing Address - Phone:808-680-0600
Mailing Address - Fax:808-680-0019
Practice Address - Street 1:91-1488 PUKANALA ST
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-4678
Practice Address - Country:US
Practice Address - Phone:808-308-5465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT-1939261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI54877900OtherALOHA CARE (GRP)
HI0000245696OtherHMSA
HI54142604Medicaid
HI3849556OtherUHA
HI400000000OtherOWCP
HI400000000OtherOWCP