Provider Demographics
NPI:1710215538
Name:MLP CHURCH MD FAMILY PRACTICE, INC.
Entity Type:Organization
Organization Name:MLP CHURCH MD FAMILY PRACTICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY LOUISE
Authorized Official - Middle Name:PARKER
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-667-6363
Mailing Address - Street 1:1707 INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28697-7345
Mailing Address - Country:US
Mailing Address - Phone:336-667-6363
Mailing Address - Fax:336-667-8066
Practice Address - Street 1:1707 INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28697-7345
Practice Address - Country:US
Practice Address - Phone:336-667-6363
Practice Address - Fax:336-667-8066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-07
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty