Provider Demographics
NPI: | 1538307384 |
---|---|
Name: | TRAVIS J. ELLIOTT ND LLC |
Entity Type: | Organization |
Organization Name: | TRAVIS J. ELLIOTT ND LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | TRAVIS |
Authorized Official - Middle Name: | J |
Authorized Official - Last Name: | ELLIOTT |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | ND |
Authorized Official - Phone: | 503-206-7773 |
Mailing Address - Street 1: | 1305 SW STEPHENSON ST |
Mailing Address - Street 2: | |
Mailing Address - City: | PORTLAND |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97219-8200 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 503-310-2036 |
Mailing Address - Fax: | 866-202-3703 |
Practice Address - Street 1: | 1340 SW BERTHA BLVD, |
Practice Address - Street 2: | SUITE 200 |
Practice Address - City: | PORTLAND |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97219 |
Practice Address - Country: | US |
Practice Address - Phone: | 503-244-0500 |
Practice Address - Fax: | 503-853-8615 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2009-02-02 |
Last Update Date: | 2012-10-26 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OR | 1281 | 175F00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 175F00000X | Other Service Providers | Naturopath | Group - Single Specialty |