=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194156604
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE CARE CENTER OF KONA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2013
-----------------------------------------------------
Last Update Date | 12/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 78-6957 KAMEHAMEHA III RD
-----------------------------------------------------
City | KAILUA KONA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96740-2528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-322-2790
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 78-6957 KAMEHAMEHA III RD
-----------------------------------------------------
City | KAILUA KONA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96740-2528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST ASSISTANT
-----------------------------------------------------
Name | POMAIKAI ANDUHA
-----------------------------------------------------
Credential | PTA
-----------------------------------------------------
Telephone | 808-322-2790
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------