Healthcare Provider Details

I. General information

NPI: 1750717864
Provider Name (Legal Business Name): TRAVIS E CORDER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2013
Last Update Date: 12/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 LEXINGTON ST
VERSAILLES KY
40383-1240
US

IV. Provider business mailing address

290 LEXINGTON ST
VERSAILLES KY
40383-1240
US

V. Phone/Fax

Practice location:
  • Phone: 859-873-5656
  • Fax: 859-873-5657
Mailing address:
  • Phone: 859-873-5656
  • Fax: 859-873-5657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number1484
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number168362
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: