=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053346783
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRAVIS PICKENS OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 10/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5211 EASON ST
-----------------------------------------------------
City | SOUTHPORT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28461-6901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-454-0563
-----------------------------------------------------
Fax | 910-454-0567
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1729 NEW HANOVER MEDICAL PARK DR
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28403-5345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-763-3601
-----------------------------------------------------
Fax | 910-763-4608
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2098
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------