Provider Demographics
NPI:1093230989
Name:TRAVIS, CHARLES LEE II
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LEE
Last Name:TRAVIS
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 MODENA COUNTRY CLB
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:NY
Mailing Address - Zip Code:12525-5702
Mailing Address - Country:US
Mailing Address - Phone:845-883-0828
Mailing Address - Fax:845-883-0828
Practice Address - Street 1:118 MODENA COUNTRY CLB
Practice Address - Street 2:
Practice Address - City:GARDINER
Practice Address - State:NY
Practice Address - Zip Code:12525
Practice Address - Country:US
Practice Address - Phone:845-883-0828
Practice Address - Fax:845-883-0828
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY401725476344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi