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General NPI Number Information
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NPI Number | 1104307842
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Entity Type | Individual
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Provider Name | TRAVIS MOULTON
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Gender | Male
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Dates
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Enumeration Date | 08/21/2018
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Last Update Date | 08/21/2018
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Provider Practice Location Address
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Address Line | 708 FAIRFIELD ST
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City | OAKLAND
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State | ME
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Zip | 04963-5220
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Country | US
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Telephone | 207-660-7363
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Fax |
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Provider Business Mailing Address
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Address Line | 708 FAIRFIELD ST
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City | OAKLAND
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State | ME
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Zip | 04963-5220
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Country | US
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Telephone | 207-660-7363
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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 | 374U00000X
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Taxonomy Name | Home Health Aide
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License Number | 03192015
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License Number State | ME
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