=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902597669
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FUKUMOTO PHYSICAL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2023
-----------------------------------------------------
Last Update Date | 05/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 94-1245 HALEULULAAU ST # A2-52
-----------------------------------------------------
City | WAIPAHU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96797-6218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-223-0496
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 94-1245 HALEULULAAU ST # A2-52
-----------------------------------------------------
City | WAIPAHU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96797-6218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | JORDAN FUKUMOTO
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 808-223-0496
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------