=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609332972
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAUKA MOVEMENT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2019
-----------------------------------------------------
Last Update Date | 02/12/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 81-965 HALEKII ST STE C
-----------------------------------------------------
City | KEALAKEKUA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96750-8164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-347-4986
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 81-965 HALEKII ST STE C
-----------------------------------------------------
City | KEALAKEKUA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96750-8164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DPT/OWNER
-----------------------------------------------------
Name | STEPHANIE NESSVIG VANHOFF
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 608-347-4986
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------