Provider Demographics
NPI:1033498811
Name:CHAMPION'S COACHING PATIENT SUPPORT AND COMPLIANCE CENTER LLC
Entity Type:Organization
Organization Name:CHAMPION'S COACHING PATIENT SUPPORT AND COMPLIANCE CENTER LLC
Other - Org Name:CHAMPION'S COACHING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CERTIFIED COACH
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEIDRA
Authorized Official - Middle Name:C
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-502-9090
Mailing Address - Street 1:6520 W MOLTKE AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1316
Mailing Address - Country:US
Mailing Address - Phone:414-502-9090
Mailing Address - Fax:414-395-3947
Practice Address - Street 1:6520 W MOLTKE AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1316
Practice Address - Country:US
Practice Address - Phone:414-502-9090
Practice Address - Fax:414-395-3947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-10
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty