Provider Demographics
NPI:1407121395
Name:CHAMPION FAMILY MEDICAL & WELLNESS
Entity Type:Organization
Organization Name:CHAMPION FAMILY MEDICAL & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMPION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-610-4041
Mailing Address - Street 1:303B HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39520-2832
Mailing Address - Country:US
Mailing Address - Phone:228-467-4431
Mailing Address - Fax:228-467-4443
Practice Address - Street 1:303B HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-2832
Practice Address - Country:US
Practice Address - Phone:228-467-4431
Practice Address - Fax:228-467-4443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty