1053062000 NPI number — CHAMPION PEDIATRIC THERAPY OF GEORGIA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053062000 NPI number — CHAMPION PEDIATRIC THERAPY OF GEORGIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHAMPION PEDIATRIC THERAPY OF GEORGIA
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:
1053062000
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1481 PLANTATION DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANDERSVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31082-7412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1481 PLANTATION DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANDERSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31082-7412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-617-8833
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/11/2022

Additional Information

Authorized Official

Authorized Official Last Name:
BRIDGES
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/OCCUPATIONAL THERAPIST
Authorized Official Telephone Number:
678-617-8833

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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