Provider Demographics
NPI:1053628065
Name:CHURCH FAMILY MEDICINE, PC
Entity type:Organization
Organization Name:CHURCH FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-755-7181
Mailing Address - Street 1:20 MEDICAL CAMPUS DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SUPPLY
Mailing Address - State:NC
Mailing Address - Zip Code:28462-4096
Mailing Address - Country:US
Mailing Address - Phone:910-755-7181
Mailing Address - Fax:910-755-7194
Practice Address - Street 1:20 MEDICAL CAMPUS DR
Practice Address - Street 2:SUITE 203
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4096
Practice Address - Country:US
Practice Address - Phone:910-755-7181
Practice Address - Fax:910-755-7194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200701334207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty