=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124644687
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHAMPION HEALTH CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2020
-----------------------------------------------------
Last Update Date | 03/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 770 5TH ST NW APT 1106
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20001-2672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-743-1775
-----------------------------------------------------
Fax | 202-301-1278
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 43923 GLENHAZEL DR
-----------------------------------------------------
City | ASHBURN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20147-3949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-743-1775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MS. ALEXA MARKS
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 202-743-1775
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------