Provider Demographics
NPI:1144929167
Name:CHURCH, KALEB (PA)
Entity type:Individual
Prefix:
First Name:KALEB
Middle Name:
Last Name:CHURCH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 KANEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2578
Mailing Address - Country:US
Mailing Address - Phone:630-584-1400
Mailing Address - Fax:630-584-1733
Practice Address - Street 1:2535 SODERQUIST CT
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-0020
Practice Address - Country:US
Practice Address - Phone:630-584-1400
Practice Address - Fax:630-584-1733
Is Sole Proprietor?:No
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085009365363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant