Provider Demographics
NPI:1881865061
Name:CHAMPAGNE, KATHE S (OPTICIAN)
Entity Type:Individual
Prefix:MRS
First Name:KATHE
Middle Name:S
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12999 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LILLIAN
Mailing Address - State:AL
Mailing Address - Zip Code:36549-4107
Mailing Address - Country:US
Mailing Address - Phone:251-962-3077
Mailing Address - Fax:251-962-3083
Practice Address - Street 1:12999 6TH STREET
Practice Address - Street 2:
Practice Address - City:LILLIAN
Practice Address - State:AL
Practice Address - Zip Code:36549-4107
Practice Address - Country:US
Practice Address - Phone:251-962-3077
Practice Address - Fax:251-962-3083
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL96872008156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0822990001OtherMEDICARE