Provider Demographics
NPI:1689225872
Name:CHURCH, LUKE
Entity Type:Individual
Prefix:
First Name:LUKE
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 1:1411 W 112TH ST APT 12
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-2372
Mailing Address - Country:US
Mailing Address - Phone:440-622-4363
Mailing Address - Fax:
Practice Address - Street 1:1411 W 112TH ST APT 12
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-2372
Practice Address - Country:US
Practice Address - Phone:440-622-4363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist