Basic Information
| Provider Information | |||||||||
| NPI: | 1487833893 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHAMPION PHYSICAL THERAPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1175 W WICKENBURG WAY STE 3 | ||||||||
| Address2: | |||||||||
| City: | WICKENBURG | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853902262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286680108 | ||||||||
| FaxNumber: | 9286680110 | ||||||||
| Practice Location | |||||||||
| Address1: | 1175 W WICKENBURG WAY STE 3 | ||||||||
| Address2: | |||||||||
| City: | WICKENBURG | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853902262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286680108 | ||||||||
| FaxNumber: | 9286680110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2007 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | FLAMAND | ||||||||
| AuthorizedOfficialFirstName: | JANELL | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9286680108 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 461893 | 05 | AZ | MEDICAID | DN7909 | 01 | AZ | RAILROAD MEDICARE | OTHER | Z118851 | 01 | AZ | MEDICARE | OTHER |