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General NPI Number Information
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NPI Number | 1053628065
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Entity Type | Organization
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Legal Business Name | CHURCH FAMILY MEDICINE, PC
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Dates
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Enumeration Date | 09/13/2010
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Last Update Date | 09/13/2010
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Provider Practice Location Address
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Address Line | 20 MEDICAL CAMPUS DR SUITE 203
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City | SUPPLY
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State | NC
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Zip | 28462-4096
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Country | US
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Telephone | 910-755-7181
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Fax | 910-755-7194
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Provider Business Mailing Address
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Address Line | 20 MEDICAL CAMPUS DR SUITE 203
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City | SUPPLY
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State | NC
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Zip | 28462-4096
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Country | US
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Telephone | 910-755-7181
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Fax | 910-755-7194
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Authorized Official
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Title or Position | OWNER
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Name | MISS LORI A CHURCH
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Credential | MD
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Telephone | 910-755-7181
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 200701334
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License Number State | NC
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