1033578331 NPI number — CHAMPION STATE OF MIND PLLC

Table of content: (NPI 1033578331)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033578331 NPI number — CHAMPION STATE OF MIND PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHAMPION STATE OF MIND PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033578331
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 36
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ESTHERVILLE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51334-0036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-592-0180
Provider Business Mailing Address Fax Number:
712-566-5229

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
508 W CENTRAL AVE
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
ESTHERVILLE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51334-1834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-592-0180
Provider Business Practice Location Address Fax Number:
712-566-5229
Provider Enumeration Date:
02/15/2016

Additional Information

Authorized Official

Authorized Official Last Name:
OLSON
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
800-592-0180

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  001653 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1033578331 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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