Provider Demographics
NPI:1457681298
Name:TRAVIS MEDICAL SALES CORPORATION
Entity Type:Organization
Organization Name:TRAVIS MEDICAL SALES CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATUKEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-756-2268
Mailing Address - Street 1:5959 SHALLOWFORD RD STE 443
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2245
Mailing Address - Country:US
Mailing Address - Phone:423-756-2268
Mailing Address - Fax:423-362-5413
Practice Address - Street 1:1724 SUNSET DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-7104
Practice Address - Country:US
Practice Address - Phone:325-223-6400
Practice Address - Fax:325-223-6404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-29
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX016016001Medicaid