Provider Demographics
NPI:1245652247
Name:N/A
Entity type:Organization
Organization Name:N/A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGISTERED RESPIRATORY THERAPIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARJORIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMPAGNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-243-0626
Mailing Address - Street 1:2261 S SHERMAN CIR
Mailing Address - Street 2:APT. A204
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-2294
Mailing Address - Country:US
Mailing Address - Phone:954-243-0626
Mailing Address - Fax:
Practice Address - Street 1:2261 S SHERMAN CIR
Practice Address - Street 2:APT. A204
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-2294
Practice Address - Country:US
Practice Address - Phone:954-243-0626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRT11166251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health