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General NPI Number Information
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NPI Number | 1124187786
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Entity Type | Organization
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Legal Business Name | COUNTRYSIDE PHYSICAL THERAPY, INC.
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Dates
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Enumeration Date | 12/08/2006
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Last Update Date | 01/22/2009
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Provider Practice Location Address
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Address Line | 67-292 GOODALE AVE #A4
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City | WAIALUA
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State | HI
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Zip | 96791
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Country | US
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Telephone | 808-637-4010
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Fax | 808-637-6020
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Provider Business Mailing Address
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Address Line | 67-188 KUHI ST
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City | WAIALUA
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State | HI
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Zip | 96791-9634
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | KYLE KIKUCHI
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Credential | DPT
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Telephone | 808-637-4010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT-2333
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License Number State | HI
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