Provider Demographics
NPI:1043369945
Name:TRAVIS, EDWIN JAY (DC CCSP CVCP ACN)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:JAY
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:DC CCSP CVCP ACN
Other - Prefix:
Other - First Name:TRAVIS
Other - Middle Name:CHIROPRACTIC
Other - Last Name:CENTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC CCSP CVCP ACN
Mailing Address - Street 1:45 LOOP 150 W
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-3930
Mailing Address - Country:US
Mailing Address - Phone:512-321-4481
Mailing Address - Fax:512-321-9737
Practice Address - Street 1:45 LOOP 150 W
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-3930
Practice Address - Country:US
Practice Address - Phone:512-321-4481
Practice Address - Fax:512-321-9737
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4037111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1226201Medicaid
TX350055841OtherRAILROAD MEDICARE
T16331Medicare UPIN
TX601338Medicare PIN