Healthcare Provider Details

I. General information

NPI: 1669949772
Provider Name (Legal Business Name): CHARLES ALLAN PITTS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2018
Last Update Date: 10/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 E MT GILEAD RD
BOLIVAR MO
65613-9128
US

IV. Provider business mailing address

965 E MT GILEAD RD
BOLIVAR MO
65613-9128
US

V. Phone/Fax

Practice location:
  • Phone: 417-327-6104
  • Fax:
Mailing address:
  • Phone: 417-327-6104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code344600000X
TaxonomyTaxi
License NumberT981478106
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License NumberS063269009
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: