Provider Demographics
NPI:1740304724
Name:KING PHYSICAL THERAPY
Entity type:Organization
Organization Name:KING PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LUCITA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-536-1011
Mailing Address - Street 1:1810 N KING ST # E1
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-3473
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1810 N KING ST # E1
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-3473
Practice Address - Country:US
Practice Address - Phone:808-536-1011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI005125-01Medicaid
HI005125-01Medicaid