Provider Demographics
NPI:1376997999
Name:CHURCH, HAYDEN
Entity Type:Individual
Prefix:
First Name:HAYDEN
Middle Name:
Last Name:CHURCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 BOONE TRL
Mailing Address - Street 2:
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-3512
Mailing Address - Country:US
Mailing Address - Phone:336-903-1700
Mailing Address - Fax:336-903-1701
Practice Address - Street 1:29 BOONE TRAIL
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659
Practice Address - Country:US
Practice Address - Phone:336-903-1700
Practice Address - Fax:336-903-1701
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2997905172A00000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No172A00000XOther Service ProvidersDriver