Healthcare Provider Details

I. General information

NPI: 1518436732
Provider Name (Legal Business Name): SUPPORT CHAMPIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2018
Last Update Date: 11/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9407 OAK MEADOW CT
TAMPA FL
33647-2526
US

IV. Provider business mailing address

PO BOX 82127
TAMPA FL
33682-2127
US

V. Phone/Fax

Practice location:
  • Phone: 813-610-9763
  • Fax: 813-436-5251
Mailing address:
  • Phone: 813-610-9763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANDREA JACKSON
Title or Position: OWNER
Credential:
Phone: 813-610-9763