Healthcare Provider Details

I. General information

NPI: 1194888552
Provider Name (Legal Business Name): SHANNON MARIE BRODERSON D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHANNON MARIE HOGAN D.C.

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74-5620 PALANI RD SUITE 102
KAILUA KONA HI
96740-3640
US

IV. Provider business mailing address

74-5620 PALANI RD SUITE 102
KAILUA KONA HI
96740-3640
US

V. Phone/Fax

Practice location:
  • Phone: 808-329-7797
  • Fax: 808-329-2748
Mailing address:
  • Phone: 808-329-7797
  • Fax: 808-329-2748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC977
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: