=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063932770
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHAMPION FAMILY CHIROPRACTIC PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2017
-----------------------------------------------------
Last Update Date | 01/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1213 GILMORE AVE
-----------------------------------------------------
City | WINONA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55987-2474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-474-2225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1213 GILMORE AVE
-----------------------------------------------------
City | WINONA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55987-2474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL UKER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 507-474-2225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 6259
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------