=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881213767
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVERY PHYSICAL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2020
-----------------------------------------------------
Last Update Date | 05/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45-167 KEANA RD
-----------------------------------------------------
City | KANEOHE
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96744-2317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-679-6542
-----------------------------------------------------
Fax | 808-235-3568
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 45-167 KEANA RD
-----------------------------------------------------
City | KANEOHE
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96744-2317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-679-6542
-----------------------------------------------------
Fax | 808-235-3568
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. GEOFFREY AVERY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 808-679-6542
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------