Healthcare Provider Details

I. General information

NPI: 1124187786
Provider Name (Legal Business Name): COUNTRYSIDE PHYSICAL THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 01/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67-292 GOODALE AVE #A4
WAIALUA HI
96791
US

IV. Provider business mailing address

67-188 KUHI ST
WAIALUA HI
96791-9634
US

V. Phone/Fax

Practice location:
  • Phone: 808-637-4010
  • Fax: 808-637-6020
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-2333
License Number StateHI

VIII. Authorized Official

Name: KYLE KIKUCHI
Title or Position: CEO
Credential: DPT
Phone: 808-637-4010