=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588953798
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHAMPION MEDICAL SYSTEMS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2011
-----------------------------------------------------
Last Update Date | 03/29/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1220 16TH ST S SUITE 100
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35205-4716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-588-6111
-----------------------------------------------------
Fax | 205-588-8113
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1220 16TH ST S SUITE 100
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35205-4716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-588-6111
-----------------------------------------------------
Fax | 205-588-8113
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING DIRECTOR
-----------------------------------------------------
Name | MR. TONY HUBERT NZERIBE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 205-588-6111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 201269
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------