Healthcare Provider Details

I. General information

NPI: 1902363849
Provider Name (Legal Business Name): RANDALL E CHAMPION
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2019
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 SOUTHWINDS RD STE 2
FARMINGTON AR
72730-8652
US

IV. Provider business mailing address

1900 STILLWATER DR
JONESBORO AR
72404-9119
US

V. Phone/Fax

Practice location:
  • Phone: 479-300-6400
  • Fax:
Mailing address:
  • Phone: 870-932-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number938795393
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: