Provider Demographics
NPI:1205302452
Name:HAWAI'I SPORTS PERFORMANCE AND REHABILITATION LLC
Entity type:Organization
Organization Name:HAWAI'I SPORTS PERFORMANCE AND REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF PHYSICAL THERAPY
Authorized Official - Prefix:DR
Authorized Official - First Name:GENELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTJE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:304-942-1726
Mailing Address - Street 1:76-6167 ALII DR
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-2387
Mailing Address - Country:US
Mailing Address - Phone:304-942-1726
Mailing Address - Fax:
Practice Address - Street 1:75-5660 KOPIKO ST
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-3611
Practice Address - Country:US
Practice Address - Phone:304-942-1726
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI12669923OtherCAQH