Provider Demographics
NPI:1871640557
Name:CHURCHILL, CHARLES CHAMP
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:CHAMP
Last Name:CHURCHILL
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 1:2650 32ND AVE S
Mailing Address - Street 2:SUITE E
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6541
Mailing Address - Country:US
Mailing Address - Phone:701-775-3905
Mailing Address - Fax:701-772-8256
Practice Address - Street 1:2650 32ND AVE S
Practice Address - Street 2:SUITE E
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6541
Practice Address - Country:US
Practice Address - Phone:701-775-3905
Practice Address - Fax:701-772-8256
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor