Healthcare Provider Details

I. General information

NPI: 1790080224
Provider Name (Legal Business Name): WILLIAM KENDALL COUCH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2011
Last Update Date: 12/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 CHURCH ST N
CONCORD NC
28025-2927
US

IV. Provider business mailing address

5025 AIRPORT CENTER PKWY BLDG L
CHARLOTTE NC
28208-5885
US

V. Phone/Fax

Practice location:
  • Phone: 704-403-3000
  • Fax:
Mailing address:
  • Phone: 704-512-7105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number207087
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: