MEDICARE: CODY DON CHAMPAGNE LMT

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	225700000X	Massage Therapist	MT135288	TX

General Provider Information

NPI Number	:	1609573955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CODY DON CHAMPAGNE LMT

Provider Business Mailing Address
First Line	:	2718 SHERMAN ST APT 216
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75051-1066
Country	:	US
Telephone Number	:	817-994-4444
Fax Number	:

Provider Business Practice Location Address
First Line	:	2718 SHERMAN ST APT 216
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75051-1066
Country	:	US
Telephone Number	:	817-994-4444
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2023
Last Update Date	:	02/07/2023

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