Organization Name: | CHAMPION FAMILY MEDICAL & WELLNESS |
NPI Number: | 1407121395 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | BRANDON CHAMPION (OWNER/MANAGER) |
Mailing Address: | 303b Highway 90 Bay St Louis |
State: | MS US |
Postal Code: | 395202832 |
Phone Number: | 2284674431 |
Fax Number: | 2284674443 |
NPI Enumeration Date: | 03/12/2012 |
NPI Last Update Date: | 03/12/2012 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363LF0000X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Nurse Practitioner |
Taxonomy Specialization: | Family |
Taxonomy Definition: |