Provider Demographics
NPI:1992910400
Name:SEASHORE INC
Entity type:Organization
Organization Name:SEASHORE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:GRETCHEN
Authorized Official - Middle Name:AMY
Authorized Official - Last Name:SEASHORE BOTHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:808-235-7999
Mailing Address - Street 1:45-1144 KAMEHAMEHA HWY
Mailing Address - Street 2:SUITE 305
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-3244
Mailing Address - Country:US
Mailing Address - Phone:808-235-7999
Mailing Address - Fax:808-235-7992
Practice Address - Street 1:45-1144 KAMEHAMEHA HWY
Practice Address - Street 2:SUITE 305
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744-3244
Practice Address - Country:US
Practice Address - Phone:808-235-7999
Practice Address - Fax:808-235-7992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2007-12-28
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
HI50023201Medicaid
HI50023201Medicaid