Healthcare Provider Details

I. General information

NPI: 1194812404
Provider Name (Legal Business Name): CHARLES RONALD COVERDALE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 03/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6830 NE BOTHELL WAY SUITE B
KENMORE WA
98028-3546
US

IV. Provider business mailing address

6830 NE BOTHELL WAY SUITE B
KENMORE WA
98028-3546
US

V. Phone/Fax

Practice location:
  • Phone: 425-485-3051
  • Fax: 425-482-2441
Mailing address:
  • Phone: 425-485-3051
  • Fax: 425-482-2441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number895
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: