Healthcare Provider Details

I. General information

NPI: 1790729606
Provider Name (Legal Business Name): ALAN D. NITAKE P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 04/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 MAKAWAO AVENUE SUITE 110
MAKAWAO HI
96768
US

IV. Provider business mailing address

28 KUINEHE PLACE
MAKAWAO HI
96768
US

V. Phone/Fax

Practice location:
  • Phone: 808-572-2281
  • Fax: 808-573-5869
Mailing address:
  • Phone: 310-528-8240
  • Fax: 310-329-9586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT6944
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-3528
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: