Healthcare Provider Details

I. General information

NPI: 1114313442
Provider Name (Legal Business Name): CHAMPION FITNESS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 04/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

548 E SPRINGFIELD RD
ARCOLA IL
61910-1801
US

IV. Provider business mailing address

924 W CUSTER AVE
PONTIAC IL
61764-1067
US

V. Phone/Fax

Practice location:
  • Phone: 217-268-3188
  • Fax: 217-268-4360
Mailing address:
  • Phone: 815-844-5411
  • Fax: 815-844-5322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL COHLMAN
Title or Position: CEO
Credential:
Phone: 815-844-5411