Provider Demographics
NPI:1114922739
Name:STODDARD, CHARLENE R (DC)
Entity Type:Individual
Prefix:DR
First Name:CHARLENE
Middle Name:R
Last Name:STODDARD
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 W IRONWOOD DR
Mailing Address - Street 2:STE 2
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-3161
Mailing Address - Country:US
Mailing Address - Phone:208-667-0875
Mailing Address - Fax:208-667-2850
Practice Address - Street 1:1025 W IRONWOOD DR
Practice Address - Street 2:STE 2
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-3161
Practice Address - Country:US
Practice Address - Phone:208-667-0875
Practice Address - Fax:208-667-2850
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA819111NS0005X
IDCHIA-819111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010022440OtherBLUE SHIELD
ID1673575Medicaid
IDC-8190OtherBLUE CROSS
ID000010022440OtherBLUE SHIELD