Provider Demographics
NPI:1669019394
Name:CHAMP VASCULAR, LLC
Entity Type:Organization
Organization Name:CHAMP VASCULAR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OGHENERUKEVWE
Authorized Official - Middle Name:
Authorized Official - Last Name:ODIETE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-400-9588
Mailing Address - Street 1:124 MORGAN DR
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-6361
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1825 HIGHWAY 34 E STE 3400
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-6423
Practice Address - Country:US
Practice Address - Phone:770-500-9588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-02
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty