Provider Demographics
NPI:1376663534
Name:DESSOFFY, TRAVIS L (CPO)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:L
Last Name:DESSOFFY
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5172 US HIGHWAY 264 E
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5805
Mailing Address - Country:US
Mailing Address - Phone:252-908-3731
Mailing Address - Fax:
Practice Address - Street 1:1025 WH SMITH BLVD STE 108
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5278
Practice Address - Country:US
Practice Address - Phone:252-215-2215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCPO02116222Z00000X, 224P00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1376663534Medicaid