1164713590 NPI number — CHAMPION MEDICAL GROUP, A MEDICAL CORPORATION

Table of content: (NPI 1164713590)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164713590 NPI number — CHAMPION MEDICAL GROUP, A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHAMPION MEDICAL GROUP, A MEDICAL CORPORATION
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:
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NPI Number Information

NPI Number:
1164713590
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2980 N BEVERLY GLEN CIR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90077-1726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-474-9809
Provider Business Mailing Address Fax Number:
888-431-8819

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2777 PACIFIC AVE
Provider Second Line Business Practice Location Address:
STE K
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90806-2625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-989-5712
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MARSHAK
Authorized Official First Name:
HERBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
562-989-5712

Provider Taxonomy Codes

  • Taxonomy code: 332900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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