Healthcare Provider Details

I. General information

NPI: 1154162840
Provider Name (Legal Business Name): MILES CHARLES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 S GRAND BLVD RM M260
SAINT LOUIS MO
63104-1004
US

IV. Provider business mailing address

1054 S KINGSHIGHWAY BLVD APT N
SAINT LOUIS MO
63110-1562
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-9851
  • Fax:
Mailing address:
  • Phone: 972-984-9589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: