Provider Demographics
NPI:1922288646
Name:CHAMPLIN PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:CHAMPLIN PHYSICAL THERAPY, LLC
Other - Org Name:PHYSICAL THERAPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHAMPLIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:307-773-8533
Mailing Address - Street 1:1951 BLUEGRASS CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-7355
Mailing Address - Country:US
Mailing Address - Phone:307-773-8533
Mailing Address - Fax:307-635-7578
Practice Address - Street 1:1951 BLUEGRASS CIRCLE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-7355
Practice Address - Country:US
Practice Address - Phone:307-773-8533
Practice Address - Fax:307-635-7578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 261QP2000X
WYPT 250225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY125527400Medicaid
WYW21628Medicare UPIN