Healthcare Provider Details

I. General information

NPI: 1275504532
Provider Name (Legal Business Name): GEORGE JOHN KUCHENREUTHER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 11/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8311 BANDFORD WAY SUITE 105
RALEIGH NC
27615-2756
US

IV. Provider business mailing address

1950 OLD GALLOWS RD SUITE 520
VIENNA VA
22182-3990
US

V. Phone/Fax

Practice location:
  • Phone: 919-870-1880
  • Fax: 919-847-4509
Mailing address:
  • Phone: 703-847-8899
  • Fax: 703-991-0514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1296
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: