Healthcare Provider Details

I. General information

NPI: 1083173983
Provider Name (Legal Business Name): TRAVIS PLYMELL PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W COLLEGE ST
LIBERTY MO
64068-1036
US

IV. Provider business mailing address

9315 BALES AVE APT 302
KANSAS CITY MO
64132-2887
US

V. Phone/Fax

Practice location:
  • Phone: 816-781-3020
  • Fax:
Mailing address:
  • Phone: 660-373-1325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2017025085
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: