Healthcare Provider Details

I. General information

NPI: 1700832045
Provider Name (Legal Business Name): TRAVIS L HOUSER IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USS ROBERT G. BRADLEY (FFG49)
FPO AA
34090-1503
US

IV. Provider business mailing address

5281 BRIGHTON PARK LN
JACKSONVILLE FL
32210
US

V. Phone/Fax

Practice location:
  • Phone: 904-270-7915
  • Fax:
Mailing address:
  • Phone: 904-619-3560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: