Provider Demographics
NPI:1922260264
Name:LAHAINA PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:LAHAINA PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER , MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHARLESTON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:808-661-5266
Mailing Address - Street 1:PO BOX 215
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-0215
Mailing Address - Country:US
Mailing Address - Phone:808-661-5266
Mailing Address - Fax:808-661-5264
Practice Address - Street 1:95 LONO AVE STE 202
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-1610
Practice Address - Country:US
Practice Address - Phone:808-661-5266
Practice Address - Fax:808-661-5264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2676261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy