Provider Demographics
NPI:1487178836
Name:PODEROSO, CHARLENE GAILE (DC)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:GAILE
Last Name:PODEROSO
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 1:94-1171 POLINAHE PL
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-4035
Mailing Address - Country:US
Mailing Address - Phone:650-524-5644
Mailing Address - Fax:
Practice Address - Street 1:94-1171 POLINAHE PL
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797
Practice Address - Country:US
Practice Address - Phone:650-524-5644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDC-1394111N00000X
CA33905111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor