Provider Demographics
NPI:1174380471
Name:CHAMPION SPORTS PERFORMANCE AND LIFE WELLNESS LLC
Entity type:Organization
Organization Name:CHAMPION SPORTS PERFORMANCE AND LIFE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUDOLPH
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:CHRISTOPHER
Authorized Official - Suffix:III
Authorized Official - Credentials:PT, MPT
Authorized Official - Phone:609-442-1212
Mailing Address - Street 1:10 RAMS GATE CT
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-9704
Mailing Address - Country:US
Mailing Address - Phone:609-442-1212
Mailing Address - Fax:609-714-9194
Practice Address - Street 1:180 ROUTE 70
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-8703
Practice Address - Country:US
Practice Address - Phone:609-442-1212
Practice Address - Fax:609-714-9194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty