=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215694898
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRAVIS HOLMES LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2021
-----------------------------------------------------
Last Update Date | 11/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 418 MAIN ST STE 800
-----------------------------------------------------
City | DICKSON CITY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18519-1774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-225-9686
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 418 MAIN ST STE 800
-----------------------------------------------------
City | DICKSON CITY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18519-1774
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-225-9686
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------