Provider Demographics
NPI:1659365724
Name:TRAVIS PHYSICAL THERAPY & SPORTS MEDICINE INC
Entity Type:Organization
Organization Name:TRAVIS PHYSICAL THERAPY & SPORTS MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:TRAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:ATC MS PT
Authorized Official - Phone:304-782-1052
Mailing Address - Street 1:RR 1 BOX 75-3
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:WV
Mailing Address - Zip Code:26426-9604
Mailing Address - Country:US
Mailing Address - Phone:304-782-1052
Mailing Address - Fax:304-782-1053
Practice Address - Street 1:RR 1 BOX 75-3
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:WV
Practice Address - Zip Code:26426-9604
Practice Address - Country:US
Practice Address - Phone:304-782-1052
Practice Address - Fax:304-782-1053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-06
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV987208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0156442000Medicaid
WV0156442000Medicaid
S01235Medicare UPIN