Healthcare Provider Details

I. General information

NPI: 1811585524
Provider Name (Legal Business Name): ORTHOSPORT PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5722 KALANIANAOLE HWY
HONOLULU HI
96821-2388
US

IV. Provider business mailing address

5722 KALANIANAOLE HWY
HONOLULU HI
96821-2388
US

V. Phone/Fax

Practice location:
  • Phone: 808-373-3555
  • Fax:
Mailing address:
  • Phone: 808-373-3555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW G. MATHIS
Title or Position: PRINCIPAL MASSAGE THERAPIST
Credential:
Phone: 808-489-8897