Provider Demographics
NPI:1487833893
Name:CHAMPION PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:CHAMPION PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANELL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FLAMAND
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:928-668-0108
Mailing Address - Street 1:1175 W WICKENBURG WAY STE 3
Mailing Address - Street 2:
Mailing Address - City:WICKENBURG
Mailing Address - State:AZ
Mailing Address - Zip Code:85390-2262
Mailing Address - Country:US
Mailing Address - Phone:928-668-0108
Mailing Address - Fax:928-668-0110
Practice Address - Street 1:1175 W WICKENBURG WAY STE 3
Practice Address - Street 2:
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390-2262
Practice Address - Country:US
Practice Address - Phone:928-668-0108
Practice Address - Fax:928-668-0110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ461893Medicaid
AZDN7909OtherRAILROAD MEDICARE
AZZ118851OtherMEDICARE