Provider Demographics
NPI:1609475565
Name:TCHAMPO, TONIKA
Entity Type:Individual
Prefix:
First Name:TONIKA
Middle Name:
Last Name:TCHAMPO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8050 TAYLOR RD APT 1101
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-4392
Mailing Address - Country:US
Mailing Address - Phone:205-276-0615
Mailing Address - Fax:
Practice Address - Street 1:8050 TAYLOR RD APT 1101
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-4392
Practice Address - Country:US
Practice Address - Phone:205-276-0615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO076418332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies