Healthcare Provider Details

I. General information

NPI: 1023837085
Provider Name (Legal Business Name): TRAVIS WAYNE KING PTA, LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

784 WALL ST STE 100P
O FALLON IL
62269-2088
US

IV. Provider business mailing address

415 S 5TH ST
CASEYVILLE IL
62232-1456
US

V. Phone/Fax

Practice location:
  • Phone: 618-550-9570
  • Fax:
Mailing address:
  • Phone: 618-550-9570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227016850
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160009325
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: