Provider Demographics
NPI:1881914117
Name:LIM, JEREMY (DPT)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:LIM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1598 ULUPII ST
Mailing Address - Street 2:
Mailing Address - City:KAILUA
Mailing Address - State:HI
Mailing Address - Zip Code:96734-4443
Mailing Address - Country:US
Mailing Address - Phone:206-890-3847
Mailing Address - Fax:888-509-9789
Practice Address - Street 1:1598 ULUPII ST
Practice Address - Street 2:
Practice Address - City:KAILUA
Practice Address - State:HI
Practice Address - Zip Code:96734-4443
Practice Address - Country:US
Practice Address - Phone:808-234-4897
Practice Address - Fax:888-509-9789
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60169739225100000X
HI3585225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8905371Medicare PIN
WAG8895479Medicare PIN