Healthcare Provider Details

I. General information

NPI: 1336379874
Provider Name (Legal Business Name): JOHN JAY KVALE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2009
Last Update Date: 07/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4353 WAIALO ROAD 11A
ELEELE HI
96705-0207
US

IV. Provider business mailing address

PO BOX 207
ELEELE HI
96705-0207
US

V. Phone/Fax

Practice location:
  • Phone: 808-335-5808
  • Fax: 808-335-5657
Mailing address:
  • Phone: 808-335-5808
  • Fax: 808-335-5657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0709-1
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: