Provider Demographics
NPI:1821632456
Name:CHAMPION MASSAGE LLC
Entity Type:Organization
Organization Name:CHAMPION MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CHAMPION
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:541-772-4399
Mailing Address - Street 1:3190 STATE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8498
Mailing Address - Country:US
Mailing Address - Phone:541-772-4399
Mailing Address - Fax:541-772-4228
Practice Address - Street 1:3190 STATE ST STE 101
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8498
Practice Address - Country:US
Practice Address - Phone:541-772-4399
Practice Address - Fax:541-772-4228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1417104381OtherSARA CHAMPION LMT