Provider Demographics
NPI:1669949772
Name:PITTS, CHARLES ALLAN
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ALLAN
Last Name:PITTS
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 1:965 E MT GILEAD RD
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-9128
Mailing Address - Country:US
Mailing Address - Phone:417-327-6104
Mailing Address - Fax:
Practice Address - Street 1:965 E MT GILEAD RD
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-9128
Practice Address - Country:US
Practice Address - Phone:417-327-6104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-26
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT981478106344600000X
MOS063269009344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi