Provider Demographics
NPI:1790386837
Name:CHAMPION RECOVERY LLC
Entity Type:Organization
Organization Name:CHAMPION RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BOBERG
Authorized Official - Suffix:
Authorized Official - Credentials:SUDC
Authorized Official - Phone:801-661-7007
Mailing Address - Street 1:222 W 540 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-6631
Mailing Address - Country:US
Mailing Address - Phone:801-661-7007
Mailing Address - Fax:
Practice Address - Street 1:222 W 540 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-6631
Practice Address - Country:US
Practice Address - Phone:801-661-7007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder