Provider Demographics
NPI:1790032829
Name:CHAMPA, JOSEPH ROBERT (LRD)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:ROBERT
Last Name:CHAMPA
Suffix:
Gender:M
Credentials:LRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2358 4TH ST W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-2433
Mailing Address - Country:US
Mailing Address - Phone:701-260-4053
Mailing Address - Fax:
Practice Address - Street 1:2358 4TH ST W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-2433
Practice Address - Country:US
Practice Address - Phone:701-260-4053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND864133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered