MEDICARE: MR. CHARLES T STATON SR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician

General Provider Information

NPI Number	:	1396927166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES T STATON SR.

Provider Business Mailing Address
First Line	:	1408 N KINGSHIGHWAY BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63113-1400
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1408 N KINGSHIGHWAY BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63113-1400
Country	:	US
Telephone Number	:	314-361-8283
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/03/2007
Last Update Date	:	12/03/2007

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Directions to “ MR. CHARLES T STATON SR. ” Practice Location

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