Healthcare Provider Details

I. General information

NPI: 1295648657
Provider Name (Legal Business Name): 1213 S CHAMPION AVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 E 1ST AVE STE 102
COLUMBUS OH
43201-3792
US

IV. Provider business mailing address

46 KNIGHTS BRIDGE DR W
PICKERINGTON OH
43147-8181
US

V. Phone/Fax

Practice location:
  • Phone: 614-216-1388
  • Fax:
Mailing address:
  • Phone: 614-216-1388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: AARON BRANDON DAVENPORT
Title or Position: OWNER
Credential:
Phone: 614-216-1388