Healthcare Provider Details

I. General information

NPI: 1407125560
Provider Name (Legal Business Name): CHARLES BIRMES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 GOLDEN POND
VILLA RIDGE MO
63089-2156
US

IV. Provider business mailing address

5800 GOLDEN POND
VILLA RIDGE MO
63089-2156
US

V. Phone/Fax

Practice location:
  • Phone: 314-560-3166
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number2010033520
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: