Healthcare Provider Details

I. General information

NPI: 1982613527
Provider Name (Legal Business Name): CHAMPION PHYSICAL THERAPY & ATHLETIC REHABILITATION, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 09/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10700 SAPP BROTHERS DR
OMAHA NE
68138-3823
US

IV. Provider business mailing address

10700 SAPP BROTHERS DR
OMAHA NE
68138-3823
US

V. Phone/Fax

Practice location:
  • Phone: 402-203-1872
  • Fax:
Mailing address:
  • Phone: 402-203-1872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1906
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number375
License Number StateNE

VIII. Authorized Official

Name: MR. BRIAN D LONG
Title or Position: PRESIDENT
Credential: PT/ATC
Phone: 402-203-1872