Provider Demographics
NPI:1376013334
Name:TRITCH, CHARLES J
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:TRITCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 SUNSET LN
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:MO
Mailing Address - Zip Code:63068-1052
Mailing Address - Country:US
Mailing Address - Phone:573-291-0873
Mailing Address - Fax:
Practice Address - Street 1:9503 MO-100
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:MO
Practice Address - Zip Code:63068
Practice Address - Country:US
Practice Address - Phone:573-237-2103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-03
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018026218225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant