Provider Demographics
NPI:1669920427
Name:CHURCH, CHARLES TAYLOR (EMT)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:TAYLOR
Last Name:CHURCH
Suffix:
Gender:M
Credentials:EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 E 300 S APT 219
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-5505
Mailing Address - Country:US
Mailing Address - Phone:801-680-5765
Mailing Address - Fax:
Practice Address - Street 1:474 WEST 200 EAST
Practice Address - Street 2:
Practice Address - City:ST. GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770
Practice Address - Country:US
Practice Address - Phone:435-634-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other