=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356208193
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHANCES MAKE CHAMPIONS LLV
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2026
-----------------------------------------------------
Last Update Date | 01/05/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4485 CANAAN PLACE DR
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27105-3048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-243-0024
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4485 CANAAN PLACE DR
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27105-3048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CHELSEY DAVIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 414-243-0024
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------