Provider Demographics
NPI:1528894706
Name:COULTER, CHARLES JR
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:COULTER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 KATHY DR
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-9730
Mailing Address - Country:US
Mailing Address - Phone:361-537-0732
Mailing Address - Fax:
Practice Address - Street 1:3600 MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-5819
Practice Address - Country:US
Practice Address - Phone:830-792-2431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX547143163WG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0100XNursing Service ProvidersRegistered NurseGastroenterology