Provider Demographics
NPI:1518326552
Name:PACIFIC SPINE & REHAB
Entity type:Organization
Organization Name:PACIFIC SPINE & REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:WRUCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:808-250-1166
Mailing Address - Street 1:PO BOX 1140
Mailing Address - Street 2:
Mailing Address - City:MAKAWAO
Mailing Address - State:HI
Mailing Address - Zip Code:96768-1140
Mailing Address - Country:US
Mailing Address - Phone:808-250-1166
Mailing Address - Fax:
Practice Address - Street 1:95 LONO AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-1610
Practice Address - Country:US
Practice Address - Phone:808-250-1166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-18
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDC726111NR0400X
HIPTA-241225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty