MEDICARE: CHAMPION'S CLINICAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1023118254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHAMPION'S CLINICAL

Provider Business Mailing Address
First Line	:	1873 PROSPECT AVE E
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44115-2313
Country	:	US
Telephone Number	:	216-589-9447
Fax Number	:	216-589-9446

Provider Business Practice Location Address
First Line	:	1873 PROSPECT AVE E
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44115-2313
Country	:	US
Telephone Number	:	216-589-9447
Fax Number	:	216-589-9446

Authorized Official
Title or Position	:	OWNER/ PRESIDENT
Name	:	MRS. TONIE CHAMPION
Credential	:
Telephone Number	:	216-589-9447

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	03/20/2008

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