Healthcare Provider Details

I. General information

NPI: 1457969594
Provider Name (Legal Business Name): TRAVIS OMMODT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3360 TITTABAWASSEE RD
SAGINAW MI
48604-9453
US

IV. Provider business mailing address

3519 VAN HORN RD
JACKSON MI
49201-9442
US

V. Phone/Fax

Practice location:
  • Phone: 989-249-6010
  • Fax: 989-249-6065
Mailing address:
  • Phone: 517-745-9082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number5302412614
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: