Healthcare Provider Details

I. General information

NPI: 1508262247
Provider Name (Legal Business Name): CHAMPION HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2014
Last Update Date: 04/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

528 W MAIN ST
LEBANON TN
37087-3403
US

IV. Provider business mailing address

528 W MAIN ST
LEBANON TN
37087-3403
US

V. Phone/Fax

Practice location:
  • Phone: 615-554-7401
  • Fax: 615-807-3303
Mailing address:
  • Phone: 615-554-7401
  • Fax: 615-807-3303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name: MR. DARRYL CHAMPION
Title or Position: ADMINISTRATOR
Credential:
Phone: 615-554-7401