Healthcare Provider Details

I. General information

NPI: 1053969915
Provider Name (Legal Business Name): TRAVIS BOLLOS VOBORIL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2019
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3438 S 148TH ST
TUKWILA WA
98168-4319
US

IV. Provider business mailing address

3438 S 148TH ST
TUKWILA WA
98168-4319
US

V. Phone/Fax

Practice location:
  • Phone: 206-832-8518
  • Fax:
Mailing address:
  • Phone: 206-832-8518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberCG61001647
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: