Healthcare Provider Details

I. General information

NPI: 1104260652
Provider Name (Legal Business Name): MR. CHARLES JUSTIN HANGGE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2013
Last Update Date: 04/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2862 CHAMPIONSHIP BLVD
SAINT LOUIS MO
63129-5269
US

IV. Provider business mailing address

3709 COURTOIS ST
SAINT LOUIS MO
63123-7712
US

V. Phone/Fax

Practice location:
  • Phone: 314-420-7375
  • Fax:
Mailing address:
  • Phone: 314-420-7375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberB-60382
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: