Healthcare Provider Details

I. General information

NPI: 1942279823
Provider Name (Legal Business Name): CHAMPION PERFORMANCE PHYSICAL THERAPY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 07/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12611 HYMEADOW DR
AUSTIN TX
78729-2700
US

IV. Provider business mailing address

PO BOX 170040
AUSTIN TX
78717-0003
US

V. Phone/Fax

Practice location:
  • Phone: 512-996-0441
  • Fax: 512-996-0442
Mailing address:
  • Phone: 512-996-0441
  • Fax: 512-996-0442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number656610000
License Number StateTX

VIII. Authorized Official

Name: CHRISTIE JEAN POWELL
Title or Position: OWNER, PHYSICAL THERAPIST
Credential: MSPT
Phone: 512-996-0441