Healthcare Provider Details

I. General information

NPI: 1700322575
Provider Name (Legal Business Name): CHAMPIONS FAMILY MEDICAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N GRAND AVE
PUEBLO CO
81003-3111
US

IV. Provider business mailing address

415 N GRAND AVE
PUEBLO CO
81003-3111
US

V. Phone/Fax

Practice location:
  • Phone: 719-924-8448
  • Fax: 719-924-9382
Mailing address:
  • Phone: 719-924-8448
  • Fax: 719-924-9382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State

VIII. Authorized Official

Name: RICHARD B LANE
Title or Position: PRACTICE MANAGER
Credential:
Phone: 719-406-9304