Healthcare Provider Details

I. General information

NPI: 1518326552
Provider Name (Legal Business Name): PACIFIC SPINE & REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2016
Last Update Date: 02/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 LONO AVE SUITE 105
KAHULUI HI
96732-1610
US

IV. Provider business mailing address

PO BOX 1140
MAKAWAO HI
96768-1140
US

V. Phone/Fax

Practice location:
  • Phone: 808-250-1166
  • Fax:
Mailing address:
  • Phone: 808-250-1166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC726
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTA-241
License Number StateHI

VIII. Authorized Official

Name: ERIC WRUCK
Title or Position: OWNER
Credential: DC
Phone: 808-250-1166