Provider Demographics
NPI:1861544413
Name:FERNANDEZ SPORTS AND PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:FERNANDEZ SPORTS AND PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:808-737-6103
Mailing Address - Street 1:4747 KILAUEA AVE
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-5308
Mailing Address - Country:US
Mailing Address - Phone:808-737-6103
Mailing Address - Fax:808-737-6072
Practice Address - Street 1:4747 KILAUEA AVE
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-5308
Practice Address - Country:US
Practice Address - Phone:808-737-6103
Practice Address - Fax:808-737-6072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI11472251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI55964Medicare ID - Type UnspecifiedGP NUMBER