Provider Information for 1891862462
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Mr. EDWARD THOMAS CHURCH III LPCC
Sex: Male
NPI: 1891862462
Last Updated: 2013-09-18
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| NPI | 1891862462 | ||||||||||||||||
| Enumeration Date | 2006-11-29 | ||||||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||||||
| Sole Proprietor | NO | ||||||||||||||||
| Status | Active | ||||||||||||||||
| Mailing Address | 4001 BLUE RIDGE PL NE ALBUQUERQUE, NM 87111-4168 United States Phone: 505-299-1634 | Fax: | ||||||||||||||||
| Primary Practice Address | 1330 SAN PEDRO DR NE SUITE 201B ALBUQUERQUE, NM 87110-6744 United States Phone: 505-260-9912 | Fax: | ||||||||||||||||
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