Provider Demographics
NPI:1154665354
Name:CHURCH, CHARLES (HIS)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:CHURCH
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 E SUNSHINE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-1160
Mailing Address - Country:US
Mailing Address - Phone:417-823-0484
Mailing Address - Fax:417-823-0484
Practice Address - Street 1:1350 E SUNSHINE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-1160
Practice Address - Country:US
Practice Address - Phone:417-823-0484
Practice Address - Fax:417-823-0484
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-12
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009018220237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist