Provider Demographics
NPI:1992991715
Name:KEAAU PHYSICAL THERAPY INC.
Entity type:Organization
Organization Name:KEAAU PHYSICAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NED
Authorized Official - Middle Name:KEN
Authorized Official - Last Name:SHIMABUKURO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:808-966-7478
Mailing Address - Street 1:16-570 KEAAU PAHOA RD
Mailing Address - Street 2:
Mailing Address - City:KEAAU
Mailing Address - State:HI
Mailing Address - Zip Code:96749-8105
Mailing Address - Country:US
Mailing Address - Phone:808-966-7478
Mailing Address - Fax:808-966-7479
Practice Address - Street 1:16-570 KEAAU PAHOA RD
Practice Address - Street 2:
Practice Address - City:KEAAU
Practice Address - State:HI
Practice Address - Zip Code:96749-8105
Practice Address - Country:US
Practice Address - Phone:808-966-7478
Practice Address - Fax:808-966-7479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-16
Last Update Date:2007-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI02588291Medicaid