Healthcare Provider Details

I. General information

NPI: 1144046681
Provider Name (Legal Business Name): CHARLAINE ROSE PORQUEZ FAENGVAD PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2024
Last Update Date: 11/30/2024
Certification Date: 11/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16400 BLANCO RD
SAN ANTONIO TX
78232-1902
US

IV. Provider business mailing address

30857 SILVERADO SPUR
BULVERDE TX
78163-2392
US

V. Phone/Fax

Practice location:
  • Phone: 210-572-4954
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1290328
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: