Healthcare Provider Details

I. General information

NPI: 1316918345
Provider Name (Legal Business Name): CHARLES ROYDEN STAUBS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2006
Last Update Date: 05/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 NAUGART DR
MERRILL WI
54452-9148
US

IV. Provider business mailing address

850 NAUGART DR
MERRILL WI
54452-9148
US

V. Phone/Fax

Practice location:
  • Phone: 715-409-0121
  • Fax:
Mailing address:
  • Phone: 715-409-0121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberH42911
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number50267-21
License Number StateWI

VIII. Authorized Official

Name: DR. CHARLES STAUBS
Title or Position: PHYSICIAN OWNER
Credential: D.O.
Phone: 715-409-0121