Healthcare Provider Details

I. General information

NPI: 1164713590
Provider Name (Legal Business Name): CHAMPION MEDICAL GROUP, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2011
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2777 PACIFIC AVE STE K
LONG BEACH CA
90806-2625
US

IV. Provider business mailing address

2980 N BEVERLY GLEN CIR SUITE 100
LOS ANGELES CA
90077-1726
US

V. Phone/Fax

Practice location:
  • Phone: 562-989-5712
  • Fax:
Mailing address:
  • Phone: 310-474-9809
  • Fax: 888-431-8819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: HERBERT MARSHAK
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 562-989-5712