Provider Demographics
NPI:1073613527
Name:CHAMPION REHABILITATION
Entity Type:Organization
Organization Name:CHAMPION REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:TOLLEFSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:619-497-1890
Mailing Address - Street 1:2918 5TH AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-5910
Mailing Address - Country:US
Mailing Address - Phone:619-497-1890
Mailing Address - Fax:619-497-1857
Practice Address - Street 1:2918 5TH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5910
Practice Address - Country:US
Practice Address - Phone:619-497-1890
Practice Address - Fax:619-497-1857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT14065225100000X
CAPT10276225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty