Basic Information
| Provider Information | |||||||||
| NPI: | 1518353861 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHAMPION FITNESS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 924 W CUSTER AVE | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617641067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158445411 | ||||||||
| FaxNumber: | 8158445322 | ||||||||
| Practice Location | |||||||||
| Address1: | 108 WATTERS DR | ||||||||
| Address2: | |||||||||
| City: | DWIGHT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604202200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155845411 | ||||||||
| FaxNumber: | 8155844803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2015 | ||||||||
| LastUpdateDate: | 04/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | COHLMAN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8158445411 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHAMPION FITNESS, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.