Provider Demographics
NPI:1386776490
Name:CHURCHILL, JOHN E (LIC AC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:E
Last Name:CHURCHILL
Suffix:
Gender:M
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 HERRICK RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON CENTRE
Mailing Address - State:MA
Mailing Address - Zip Code:02459-2217
Mailing Address - Country:US
Mailing Address - Phone:617-244-0469
Mailing Address - Fax:
Practice Address - Street 1:796 BEACON ST
Practice Address - Street 2:SAMADHI
Practice Address - City:NEWTON CENTRE
Practice Address - State:MA
Practice Address - Zip Code:02459-1935
Practice Address - Country:US
Practice Address - Phone:617-244-0469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA221046171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist