Provider Demographics
NPI:1659560035
Name:CHAMPION CHIROPRACTIC, INC
Entity Type:Organization
Organization Name:CHAMPION CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTONDI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:502-459-9321
Mailing Address - Street 1:332 W BROADWAY
Mailing Address - Street 2:#801
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:332 W BROADWAY
Practice Address - Street 2:#801
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-2130
Practice Address - Country:US
Practice Address - Phone:502-459-9321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4467111N00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No305S00000XManaged Care OrganizationsPoint of ServiceGroup - Single Specialty