Provider Demographics
NPI:1083931448
Name:PEACOCK, TRAVIS JEFFREY (LMT)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:JEFFREY
Last Name:PEACOCK
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10100 US HIGHWAY 231
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:KY
Mailing Address - Zip Code:42376-9340
Mailing Address - Country:US
Mailing Address - Phone:270-925-0024
Mailing Address - Fax:
Practice Address - Street 1:10100 US HIGHWAY 231
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:KY
Practice Address - Zip Code:42376-9340
Practice Address - Country:US
Practice Address - Phone:270-925-0024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY3559225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist