Provider Demographics
NPI:1689852899
Name:MORISOLI, TRAVIS JAMES
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JAMES
Last Name:MORISOLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2951 HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3912
Mailing Address - Country:US
Mailing Address - Phone:714-427-0803
Mailing Address - Fax:
Practice Address - Street 1:22 CORPORATE PLAZA DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7985
Practice Address - Country:US
Practice Address - Phone:949-722-5054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-11
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA344312251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports