Provider Demographics
NPI:1962210583
Name:CHURCH, DAESHA ALORA
Entity type:Individual
Prefix:
First Name:DAESHA
Middle Name:ALORA
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 1:2909 LORETTA CT
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44052-4468
Mailing Address - Country:US
Mailing Address - Phone:440-989-6935
Mailing Address - Fax:
Practice Address - Street 1:2909 LORETTA CT
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44052-4468
Practice Address - Country:US
Practice Address - Phone:440-989-6935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-28
Last Update Date:2024-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHHGF1098172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver