Provider Demographics
NPI:1629267638
Name:TRAVIDC, LLC
Entity Type:Organization
Organization Name:TRAVIDC, LLC
Other - Org Name:THE BODY SHOP CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:856-354-0044
Mailing Address - Street 1:13 TANNER ST
Mailing Address - Street 2:
Mailing Address - City:HADDONFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08033-2470
Mailing Address - Country:US
Mailing Address - Phone:856-354-0044
Mailing Address - Fax:856-354-1944
Practice Address - Street 1:13 TANNER ST
Practice Address - Street 2:
Practice Address - City:HADDONFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08033-2470
Practice Address - Country:US
Practice Address - Phone:856-354-0044
Practice Address - Fax:856-354-1944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00543800111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty