=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225746183
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHAMPION COMMUNITY CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2022
-----------------------------------------------------
Last Update Date | 06/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3869 SOUTH FWY
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76110-5600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-302-4267
-----------------------------------------------------
Fax | 682-703-1080
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4804 ALANDALE DR
-----------------------------------------------------
City | FOREST HILL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76119-7508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-302-4267
-----------------------------------------------------
Fax | 682-703-1080
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR/OWNER
-----------------------------------------------------
Name | GLORIA JEAN SINGLETON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 682-302-4267
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------