Provider Demographics
NPI:1700322575
Name:CHAMPIONS FAMILY MEDICAL, PLLC
Entity Type:Organization
Organization Name:CHAMPIONS FAMILY MEDICAL, PLLC
Other - Org Name:CHAMPIONS FAMILY MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-406-9304
Mailing Address - Street 1:415 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3111
Mailing Address - Country:US
Mailing Address - Phone:719-924-8448
Mailing Address - Fax:719-924-9382
Practice Address - Street 1:415 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3111
Practice Address - Country:US
Practice Address - Phone:719-924-8448
Practice Address - Fax:719-924-9382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty