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General NPI Number Information
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NPI Number | 1023837085
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Entity Type | Individual
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Provider Name | TRAVIS WAYNE KING PTA, LMT
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Gender | Male
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Dates
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Enumeration Date | 10/07/2024
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Last Update Date | 10/07/2024
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Provider Practice Location Address
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Address Line | 784 WALL ST STE 100P
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City | O FALLON
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State | IL
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Zip | 62269-2088
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Country | US
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Telephone | 618-550-9570
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Fax |
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Provider Business Mailing Address
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Address Line | 415 S 5TH ST
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City | CASEYVILLE
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State | IL
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Zip | 62232-1456
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Country | US
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Telephone | 618-550-9570
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 227016850
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 160009325
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License Number State | IL
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