Healthcare Provider Details

I. General information

NPI: 1629207956
Provider Name (Legal Business Name): JONATHAN SORIANO CAMACAYLAN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2009
Last Update Date: 07/21/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68-1845 WAIKOLOA RD STE 211
WAIKOLOA HI
96738
US

IV. Provider business mailing address

68-1845 WAIKOLOA RD STE 106 # 220
WAIKOLOA HI
96738
US

V. Phone/Fax

Practice location:
  • Phone: 808-883-3400
  • Fax: 808-883-3440
Mailing address:
  • Phone: 808-883-3400
  • Fax: 808-883-3440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-2935
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: