Provider Demographics
NPI:1982760922
Name:TRAVIS OPTICAL
Entity Type:Organization
Organization Name:TRAVIS OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:TRAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:919-477-4006
Mailing Address - Street 1:PO BOX 15118
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-0118
Mailing Address - Country:US
Mailing Address - Phone:919-477-4006
Mailing Address - Fax:
Practice Address - Street 1:3901 N ROXBORO RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-0118
Practice Address - Country:US
Practice Address - Phone:919-477-4006
Practice Address - Fax:919-477-4006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC341156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8801919Medicaid
NC8801919Medicaid