Provider Demographics
NPI:1952878498
Name:CHAMPAGNE, BRENT MICHAEL
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:MICHAEL
Last Name:CHAMPAGNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21756 STATE ROAD 54
Mailing Address - Street 2:STE 102
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-2905
Mailing Address - Country:US
Mailing Address - Phone:727-475-5540
Mailing Address - Fax:
Practice Address - Street 1:5606 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:HARAHAN
Practice Address - State:LA
Practice Address - Zip Code:70123-5111
Practice Address - Country:US
Practice Address - Phone:504-733-0254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic