Provider Demographics
NPI:1477659738
Name:GHOLSON, TRAVIS RHINE (DC)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:RHINE
Last Name:GHOLSON
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 1:1600 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:CARMI
Mailing Address - State:IL
Mailing Address - Zip Code:62821-2214
Mailing Address - Country:US
Mailing Address - Phone:618-378-3330
Mailing Address - Fax:618-378-3450
Practice Address - Street 1:120 S DIVISION
Practice Address - Street 2:
Practice Address - City:NORRIS CITY
Practice Address - State:IL
Practice Address - Zip Code:62869
Practice Address - Country:US
Practice Address - Phone:618-378-3330
Practice Address - Fax:618-378-3450
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008660111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09726159OtherBLUE CROSS BLUE SHIELD
IL038008660Medicaid
573380Medicare ID - Type Unspecified