Provider Demographics
NPI:1306036223
Name:CHAMPION FAMILY CARE HOME
Entity Type:Organization
Organization Name:CHAMPION FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMPION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-434-7727
Mailing Address - Street 1:127 LUCAS LN
Mailing Address - Street 2:
Mailing Address - City:MOORESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28114-6799
Mailing Address - Country:US
Mailing Address - Phone:704-494-7727
Mailing Address - Fax:
Practice Address - Street 1:127 LUCAS LN
Practice Address - Street 2:
Practice Address - City:MOORESBORO
Practice Address - State:NC
Practice Address - Zip Code:28114-6799
Practice Address - Country:US
Practice Address - Phone:704-434-7727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805153Medicaid