MEDICARE: CHAMPION REHABILITATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT10276	CA
2	225100000X	Physical Therapist	PT14065	CA

General Provider Information

NPI Number	:	1073613527
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHAMPION REHABILITATION

Provider Business Mailing Address
First Line	:	2918 5TH AVE
Second Line	:	SUITE 101
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-5910
Country	:	US
Telephone Number	:	619-497-1890
Fax Number	:	619-497-1857

Provider Business Practice Location Address
First Line	:	2918 5TH AVE
Second Line	:	SUITE 101
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-5910
Country	:	US
Telephone Number	:	619-497-1890
Fax Number	:	619-497-1857

Authorized Official
Title or Position	:	OWNER
Name	:	MR. KEVIN DEE TOLLEFSON
Credential	:	PHYSICAL THERAPIST
Telephone Number	:	619-497-1890

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	08/22/2020

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Directions to “CHAMPION REHABILITATION ” Practice Location

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