Healthcare Provider Details

I. General information

NPI: 1255650867
Provider Name (Legal Business Name): DARRYL DESHAWN CHAMPION MDX
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2010
Last Update Date: 05/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 LEALAND LANE
LEBANON TN
37087
US

IV. Provider business mailing address

444 LEALAND LANE
LEBANON TN
37087
US

V. Phone/Fax

Practice location:
  • Phone: 615-554-7401
  • Fax: 615-547-9323
Mailing address:
  • Phone: 615-554-7401
  • Fax: 615-547-9323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: