=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356161509
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DESOTO VISION CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2024
-----------------------------------------------------
Last Update Date | 11/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 126 S MAIN ST
-----------------------------------------------------
City | DE SOTO
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63020-2104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-586-5406
-----------------------------------------------------
Fax | 636-586-1969
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 126 S MAIN ST
-----------------------------------------------------
City | DE SOTO
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63020-2104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-586-5406
-----------------------------------------------------
Fax | 636-586-1969
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. CHARLES W PELTON
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 636-586-5406
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------