Provider Demographics
NPI:1053690016
Name:CHAMPIONS SPINE CENTER PA
Entity Type:Organization
Organization Name:CHAMPIONS SPINE CENTER PA
Other - Org Name:LAKE JACKSON FAMILY PRACTICE PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-774-5462
Mailing Address - Street 1:14450 TC JESTER BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77014-1332
Mailing Address - Country:US
Mailing Address - Phone:713-774-5462
Mailing Address - Fax:713-774-5478
Practice Address - Street 1:135 OYSTER CREEK DR STE W
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-4117
Practice Address - Country:US
Practice Address - Phone:979-299-1200
Practice Address - Fax:979-299-1205
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHAMPIONS SPINE CENTER PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3996207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty