Provider Demographics
NPI:1124645684
Name:CHAMPION PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:CHAMPION PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:P
Authorized Official - Last Name:ROWE
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:985-768-0980
Mailing Address - Street 1:901 LAKELAND PL STE 9
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-6633
Mailing Address - Country:US
Mailing Address - Phone:769-251-1148
Mailing Address - Fax:769-216-2156
Practice Address - Street 1:901 LAKELAND PL STE 9
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-6633
Practice Address - Country:US
Practice Address - Phone:769-251-1148
Practice Address - Fax:769-216-2156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-01
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty