Provider Demographics
NPI:1023837085
Name:KING, TRAVIS WAYNE (PTA, LMT)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:WAYNE
Last Name:KING
Suffix:
Gender:M
Credentials:PTA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CASEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62232-1456
Mailing Address - Country:US
Mailing Address - Phone:618-550-9570
Mailing Address - Fax:
Practice Address - Street 1:784 WALL ST STE 100P
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-2088
Practice Address - Country:US
Practice Address - Phone:618-550-9570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227016850225700000X
IL160009325225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist