Provider Demographics
NPI:1457530149
Name:CHAMPION PHYSICAL THERAPY AND FITNESS
Entity type:Organization
Organization Name:CHAMPION PHYSICAL THERAPY AND FITNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:P
Authorized Official - Last Name:WYNEKEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:317-797-4797
Mailing Address - Street 1:496 COBBLESTONE PL
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-9422
Mailing Address - Country:US
Mailing Address - Phone:317-797-4797
Mailing Address - Fax:
Practice Address - Street 1:65 E GARNER RD STE 100
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-7867
Practice Address - Country:US
Practice Address - Phone:317-797-4797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05006312A261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy