Healthcare Provider Details

I. General information

NPI: 1528868015
Provider Name (Legal Business Name): CHAD TILLMAN COUCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2025
Last Update Date: 08/30/2026
Certification Date: 08/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1395 CENTER DR
GAINESVILLE FL
32610-0001
US

IV. Provider business mailing address

108 HENRY ANNA LN
BRISTOL TN
37620-3144
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-6705
  • Fax:
Mailing address:
  • Phone: 423-956-4923
  • Fax: 423-956-4923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberDRPM3079
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: