Provider Demographics
NPI:1942279823
Name:CHAMPION PERFORMANCE PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:CHAMPION PERFORMANCE PHYSICAL THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIE
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:512-996-0441
Mailing Address - Street 1:PO BOX 170040
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-0003
Mailing Address - Country:US
Mailing Address - Phone:512-996-0441
Mailing Address - Fax:512-996-0442
Practice Address - Street 1:12611 HYMEADOW DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78729-2700
Practice Address - Country:US
Practice Address - Phone:512-996-0441
Practice Address - Fax:512-996-0442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX656610000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3418380OtherCIGNA
TX0045MROtherBC/BS PROVIDER NUMBER
TX7141718OtherAETNA
TX3418380OtherCIGNA