Healthcare Provider Details

I. General information

NPI: 1114922739
Provider Name (Legal Business Name): CHARLENE R STODDARD D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 W IRONWOOD DR STE 2
COEUR D ALENE ID
83814-3161
US

IV. Provider business mailing address

1025 W IRONWOOD DR STE 2
COEUR D ALENE ID
83814-3161
US

V. Phone/Fax

Practice location:
  • Phone: 208-667-0875
  • Fax: 208-667-2850
Mailing address:
  • Phone: 208-667-0875
  • Fax: 208-667-2850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCHIA819
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA-819
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: