=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841955242
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE FORGE - HEALTH AND FITNESS GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2021
-----------------------------------------------------
Last Update Date | 11/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 955 WAIMANU ST
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96814-3319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-818-3433
-----------------------------------------------------
Fax | 808-427-6071
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1520 WARD AVE APT 904
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96822-3556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | JUSTIN FUKUNAGA
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 808-551-8648
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------