Healthcare Provider Details

I. General information

NPI: 1760953327
Provider Name (Legal Business Name): TRAVIS ALEXANDER YOUNG CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2018
Last Update Date: 02/24/2020
Certification Date: 02/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7015 N CHESTNUT AVE STE 103
FRESNO CA
93720-0349
US

IV. Provider business mailing address

1247 E ALLUVIAL AVE STE 103
FRESNO CA
93720-2686
US

V. Phone/Fax

Practice location:
  • Phone: 559-298-0321
  • Fax:
Mailing address:
  • Phone: 559-298-0321
  • Fax: 559-298-7164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberCPO04430
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCPO04430
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: