Provider Demographics
NPI:1982613527
Name:CHAMPION PHYSICAL THERAPY & ATHLETIC REHABILITATION, PC
Entity Type:Organization
Organization Name:CHAMPION PHYSICAL THERAPY & ATHLETIC REHABILITATION, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:PT/ATC
Authorized Official - Phone:402-203-1872
Mailing Address - Street 1:10700 SAPP BROTHERS DR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68138-3823
Mailing Address - Country:US
Mailing Address - Phone:402-203-1872
Mailing Address - Fax:
Practice Address - Street 1:10700 SAPP BROTHERS DR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68138-3823
Practice Address - Country:US
Practice Address - Phone:402-203-1872
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1906225100000X
NE3752255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE02148OtherBLUE CROSS BLUE SHEILD
NE10025424600Medicaid
NE10025424600Medicaid