Provider Demographics
NPI:1487998183
Name:CHAMPION PROFESSIONAL SERVICES
Entity type:Organization
Organization Name:CHAMPION PROFESSIONAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:LYONS
Authorized Official - Suffix:
Authorized Official - Credentials:MS,,PT
Authorized Official - Phone:631-828-4373
Mailing Address - Street 1:93 TALLMADGE TRL
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-2327
Mailing Address - Country:US
Mailing Address - Phone:631-828-4373
Mailing Address - Fax:631-828-4373
Practice Address - Street 1:93 TALLMADGE TRL
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-2327
Practice Address - Country:US
Practice Address - Phone:631-828-4373
Practice Address - Fax:631-828-4373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY187752251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Single Specialty