Provider Demographics
NPI:1073056206
Name:CHURCH, MICHAEL BRANDON (LPTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRANDON
Last Name:CHURCH
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1996 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1940
Mailing Address - Country:US
Mailing Address - Phone:423-844-6111
Mailing Address - Fax:
Practice Address - Street 1:1996 W STATE ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-1940
Practice Address - Country:US
Practice Address - Phone:423-844-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-20
Last Update Date:2016-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6152225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant