Provider Demographics
NPI:1942981873
Name:CHURCH STREET MEDICAL CENTER AND AESTHETICS
Entity type:Organization
Organization Name:CHURCH STREET MEDICAL CENTER AND AESTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BENNETT WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:276-239-0338
Mailing Address - Street 1:214 CHURCH ST NW
Mailing Address - Street 2:
Mailing Address - City:LENOIR
Mailing Address - State:NC
Mailing Address - Zip Code:28645-5117
Mailing Address - Country:US
Mailing Address - Phone:276-239-0338
Mailing Address - Fax:
Practice Address - Street 1:214 CHURCH ST NW
Practice Address - Street 2:
Practice Address - City:LENOIR
Practice Address - State:NC
Practice Address - Zip Code:28645-5117
Practice Address - Country:US
Practice Address - Phone:276-239-0338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty