MEDICARE: CHAMPION PERFORMANCE PHYSICAL THERAPY, PC

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	656610000	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3418380	OTHER	TX	CIGNA
2	0045MR	OTHER	TX	BC/BS PROVIDER NUMBER
3	7141718	OTHER	TX	AETNA

General Provider Information

NPI Number	:	1942279823
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHAMPION PERFORMANCE PHYSICAL THERAPY, PC

Provider Business Mailing Address
First Line	:	PO BOX 170040
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78717-0003
Country	:	US
Telephone Number	:	512-996-0441
Fax Number	:	512-996-0442

Provider Business Practice Location Address
First Line	:	12611 HYMEADOW DR
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78729-2700
Country	:	US
Telephone Number	:	512-996-0441
Fax Number	:	512-996-0442

Authorized Official
Title or Position	:	OWNER, PHYSICAL THERAPIST
Name	:	CHRISTIE JEAN POWELL
Credential	:	MSPT
Telephone Number	:	512-996-0441

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	07/28/2010

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