Provider Demographics
NPI:1649058959
Name:CHURCHILL, MALCOLM (LVN)
Entity type:Individual
Prefix:
First Name:MALCOLM
Middle Name:
Last Name:CHURCHILL
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3055 WILSHIRE BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-1147
Mailing Address - Country:US
Mailing Address - Phone:626-533-2313
Mailing Address - Fax:
Practice Address - Street 1:609 W 73RD ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044
Practice Address - Country:US
Practice Address - Phone:626-533-2313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA724318164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse