Provider Demographics
NPI:1184731259
Name:CHAMPIONSHIP PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:CHAMPIONSHIP PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:SQUIRES
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:617-846-5609
Mailing Address - Street 1:120 BANKS ST
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:MA
Mailing Address - Zip Code:02152
Mailing Address - Country:US
Mailing Address - Phone:617-846-5609
Mailing Address - Fax:617-539-0025
Practice Address - Street 1:120 BANKS ST
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:MA
Practice Address - Zip Code:02152
Practice Address - Country:US
Practice Address - Phone:617-846-5609
Practice Address - Fax:617-539-0025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
9774548OtherMASSHEALTH
112846OtherAETNA
831662OtherTUFTS
DD2189OtherMEDICARE RR
0034886OtherNEIGHBORHOOD HEALTH
606436OtherHARVARD PILGRIM
6400011OtherUNITED HEALTHCARE
MA9774548Medicaid
9774548OtherMASSHEALTH