Provider Demographics
NPI:1124741467
Name:EWA BEACH PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:EWA BEACH PHYSICAL THERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:H
Authorized Official - Last Name:TAKIGUCHI
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:808-689-9994
Mailing Address - Street 1:91-2139 FORT WEAVER RD STE 210
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-3609
Mailing Address - Country:US
Mailing Address - Phone:808-689-9994
Mailing Address - Fax:808-689-9995
Practice Address - Street 1:91-1121 KEAUNUI DR STE 203
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-6366
Practice Address - Country:US
Practice Address - Phone:808-689-9994
Practice Address - Fax:808-689-9995
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EWA BEACH PHYSICAL THERAPY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-09-21
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI024988OtherHMSA
HI768765Medicaid