Healthcare Provider Details

I. General information

NPI: 1356161509
Provider Name (Legal Business Name): DESOTO VISION CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 S MAIN ST
DE SOTO MO
63020-2104
US

IV. Provider business mailing address

126 S MAIN ST
DE SOTO MO
63020-2104
US

V. Phone/Fax

Practice location:
  • Phone: 636-586-5406
  • Fax: 636-586-1969
Mailing address:
  • Phone: 636-586-5406
  • Fax: 636-586-1969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. CHARLES W PELTON
Title or Position: OPTOMETRIST
Credential: OD
Phone: 636-586-5406