Provider Demographics
NPI:1962615021
Name:MONTICELLO, CHARLENE PHYLLIS (DC)
Entity type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:PHYLLIS
Last Name:MONTICELLO
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 1:269 AVIATION BLVD., STE. 102
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492-9540
Mailing Address - Country:US
Mailing Address - Phone:707-836-1333
Mailing Address - Fax:707-838-4382
Practice Address - Street 1:269 AVIATION BLVD
Practice Address - Street 2:STE 102
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-9017
Practice Address - Country:US
Practice Address - Phone:707-836-1333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27131111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC 0271310Medicare ID - Type Unspecified