Healthcare Provider Details

I. General information

NPI: 1245244912
Provider Name (Legal Business Name): IMPACT SPORTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4381 KUKUI GROVE ST SUITE 3
LIHUE HI
96766
US

IV. Provider business mailing address

4381 KUKUI GROVE ST SUITE 3
LIHUE HI
96766
US

V. Phone/Fax

Practice location:
  • Phone: 808-246-0144
  • Fax: 808-245-5148
Mailing address:
  • Phone: 808-246-0144
  • Fax: 808-245-5148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: STEVE NAKAMURA
Title or Position: PRESIDENT
Credential: PT
Phone: 808-246-0144