Healthcare Provider Details

I. General information

NPI: 1588970990
Provider Name (Legal Business Name): DARRYL CHAMPION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2010
Last Update Date: 04/07/2011
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 TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number StateTN

VIII. Authorized Official

Name: MR. DARRYL D. CHAMPION
Title or Position: OWNER/TECH
Credential: MDV
Phone: 615-554-7401