=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922582865
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KOMD HAWAII LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2018
-----------------------------------------------------
Last Update Date | 10/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 55 S JUDD ST APT 1004
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96817-2610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-551-8648
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55 S JUDD ST APT 1004
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96817-2610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST/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 |
-----------------------------------------------------