Provider Demographics
NPI:1285306589
Name:PROXIMAL PHYSICAL THERAPY AND WELLNESS LLC
Entity type:Organization
Organization Name:PROXIMAL PHYSICAL THERAPY AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF PT
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:SAGUIGUIT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:808-796-3310
Mailing Address - Street 1:PO BOX 492907
Mailing Address - Street 2:
Mailing Address - City:KEAAU
Mailing Address - State:HI
Mailing Address - Zip Code:96749-2907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15-2984 PAHOA VILLAGE RD
Practice Address - Street 2:
Practice Address - City:PAHOA
Practice Address - State:HI
Practice Address - Zip Code:96778
Practice Address - Country:US
Practice Address - Phone:808-796-3310
Practice Address - Fax:808-796-3309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI1770940413Medicaid