Provider Demographics
NPI:1861592123
Name:CHARLESTON, BROCK A (PT)
Entity type:Individual
Prefix:
First Name:BROCK
Middle Name:A
Last Name:CHARLESTON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 215
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-0215
Mailing Address - Country:US
Mailing Address - Phone:808-661-5266
Mailing Address - Fax:808-661-5264
Practice Address - Street 1:161 WAILEA IKE PL STE A105
Practice Address - Street 2:
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-6502
Practice Address - Country:US
Practice Address - Phone:808-661-5266
Practice Address - Fax:808-661-5264
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT 2676225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist