Healthcare Provider Details

I. General information

NPI: 1063606937
Provider Name (Legal Business Name): CHARLES ROGGOW ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 A 'APUEO PARKWAY
PUKALANI HI
96768
US

IV. Provider business mailing address

124 ALEIKI PL
PAIA HI
96779-9716
US

V. Phone/Fax

Practice location:
  • Phone: 808-573-7108
  • Fax:
Mailing address:
  • Phone: 808-579-8626
  • Fax: 808-579-8630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2255A2300X
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: