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NPI Code Detail

MEDICARE: TRAVIS BREAZEALE PT

MEDICARE: TRAVIS BREAZEALE PT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist1236842TX

General Provider Information

NPI Number : 1154751717
Entity Type Code : Individual
Provider Name (Legal Business Name) : TRAVIS BREAZEALE PT
Provider Business Mailing Address
First Line : 1324 COMMON ST STE 307
Second Line :
City : NEW BRAUNFELS
State : TX
Zip : 78130-3566
Country : US
Telephone Number : 830-625-7130
Fax Number : 830-625-3228
Provider Business Practice Location Address
First Line : 1330 BOILING SPRINGS RD STE 1600
Second Line :
City : SPARTANBURG
State : SC
Zip : 29303-4219
Country : US
Telephone Number : 803-732-5887
Fax Number : 803-732-5997
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/19/2013
Last Update Date : 05/15/2019

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