Provider Demographics
NPI:1235521360
Name:MALOTT, TRAVIS (DC)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:MALOTT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E101 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:BRODHEAD
Mailing Address - State:WI
Mailing Address - Zip Code:53520-2003
Mailing Address - Country:US
Mailing Address - Phone:608-897-3010
Mailing Address - Fax:608-897-3011
Practice Address - Street 1:E101 4TH STREET
Practice Address - Street 2:
Practice Address - City:BRODHEAD
Practice Address - State:WI
Practice Address - Zip Code:53520-2003
Practice Address - Country:US
Practice Address - Phone:608-897-3010
Practice Address - Fax:608-897-3011
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5080-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor