Provider Demographics
NPI:1124107347
Name:CHURCH, KIMBERLY C
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:C
Last Name:CHURCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4423 MANESS RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-8635
Mailing Address - Country:US
Mailing Address - Phone:336-621-1163
Mailing Address - Fax:336-621-1163
Practice Address - Street 1:3917 BURLINGTON RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-8652
Practice Address - Country:US
Practice Address - Phone:336-621-1163
Practice Address - Fax:336-621-1163
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00671332B00000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4411700001Medicare NSC