Healthcare Provider Details

I. General information

NPI: 1326466574
Provider Name (Legal Business Name): KENT WILLIS COCHRAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2014
Last Update Date: 04/26/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 E KINDERTON WAY STE 101
BERMUDA RUN NC
27006
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-893-3210
  • Fax: 336-893-3229
Mailing address:
  • Phone: 336-893-3210
  • Fax: 336-893-3229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2016-00786
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number207LP2900X
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: