Basic Information
| Provider Information | |||||||||
| NPI: | 1760971980 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHAMPIONS RECOVERY ROOM AND PHYSICAL THERAPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3030 100TH ST | ||||||||
| Address2: | |||||||||
| City: | URBANDALE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503223865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5154102908 | ||||||||
| FaxNumber: | 5154102909 | ||||||||
| Practice Location | |||||||||
| Address1: | 3030 100TH ST | ||||||||
| Address2: | |||||||||
| City: | URBANDALE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503223865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5154102908 | ||||||||
| FaxNumber: | 5154102909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2018 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | SPENCER | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 5157209145 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT, MSPT, CMPT, CAFS | ||||||||
| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.