Provider Demographics
NPI:1295880755
Name:CHAMPION CHIROPRACTIC & REHAB INC
Entity type:Organization
Organization Name:CHAMPION CHIROPRACTIC & REHAB INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAMIAN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:FRONZAGLIA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:954-228-4635
Mailing Address - Street 1:9768 W SAMPLE RD
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-4004
Mailing Address - Country:US
Mailing Address - Phone:954-228-4635
Mailing Address - Fax:754-229-8712
Practice Address - Street 1:9768 W SAMPLE RD
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065
Practice Address - Country:US
Practice Address - Phone:954-228-4635
Practice Address - Fax:754-229-8712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7734111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTIN
FL=========OtherTIN