Provider Demographics
NPI:1497266365
Name:CHAMPION FAMILY HEALTHCARE SERVICES, LLC
Entity Type:Organization
Organization Name:CHAMPION FAMILY HEALTHCARE SERVICES, LLC
Other - Org Name:KESTON CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTOINETTE
Authorized Official - Middle Name:LOIS
Authorized Official - Last Name:VAN-RIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-608-4612
Mailing Address - Street 1:1410 MILLGATE DR STE A
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1336
Mailing Address - Country:US
Mailing Address - Phone:336-608-4612
Mailing Address - Fax:336-608-4739
Practice Address - Street 1:1410 MILLGATE DR STE A
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1336
Practice Address - Country:US
Practice Address - Phone:336-608-4612
Practice Address - Fax:336-608-4739
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHAMPION FAMILY HEALTHCARE SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-19
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC1170251E00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC34008537Medicaid
NC6600279Medicaid