Healthcare Provider Details

I. General information

NPI: 1033498811
Provider Name (Legal Business Name): CHAMPION'S COACHING PATIENT SUPPORT AND COMPLIANCE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2011
Last Update Date: 08/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6520 W MOLTKE AVE
MILWAUKEE WI
53210-1316
US

IV. Provider business mailing address

6520 W MOLTKE AVE
MILWAUKEE WI
53210-1316
US

V. Phone/Fax

Practice location:
  • Phone: 414-502-9090
  • Fax: 414-395-3947
Mailing address:
  • Phone: 414-502-9090
  • Fax: 414-395-3947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEIDRA C HALL
Title or Position: OWNER/CERTIFIED COACH
Credential:
Phone: 414-502-9090