Healthcare Provider Details

I. General information

NPI: 1508496001
Provider Name (Legal Business Name): TRAVIS WHITE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 JEWETT RD
MASON MI
48854-8729
US

IV. Provider business mailing address

PO BOX 289
MASON MI
48854-0289
US

V. Phone/Fax

Practice location:
  • Phone: 517-676-5405
  • Fax: 517-676-5460
Mailing address:
  • Phone: 517-676-5405
  • Fax: 517-676-5460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: