Provider Demographics
NPI:1437336955
Name:CHAMPION MEDICAL SUPPLY
Entity Type:Organization
Organization Name:CHAMPION MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-462-1944
Mailing Address - Street 1:1996 GLENTANA STREET
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065
Mailing Address - Country:US
Mailing Address - Phone:310-462-1944
Mailing Address - Fax:805-582-9873
Practice Address - Street 1:1996 GLENTANA ST
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-0553
Practice Address - Country:US
Practice Address - Phone:310-462-1944
Practice Address - Fax:805-582-9873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies