Provider Demographics
NPI:1760500177
Name:ANDY AND PATTY CHAMPION OD PA
Entity Type:Organization
Organization Name:ANDY AND PATTY CHAMPION OD PA
Other - Org Name:CHAMPION EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:P
Authorized Official - Last Name:CHAMPION
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:828-650-2727
Mailing Address - Street 1:300 JULIAN LN
Mailing Address - Street 2:
Mailing Address - City:ARDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28704-7809
Mailing Address - Country:US
Mailing Address - Phone:828-650-2727
Mailing Address - Fax:828-650-2725
Practice Address - Street 1:300 JULIAN LN
Practice Address - Street 2:
Practice Address - City:ARDEN
Practice Address - State:NC
Practice Address - Zip Code:28704-7809
Practice Address - Country:US
Practice Address - Phone:828-650-2727
Practice Address - Fax:828-650-2725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1541152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0213LOtherBCBS
NC5917340Medicaid
NC1248120001Medicare NSC
NC5917340Medicaid