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General NPI Number Information
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NPI Number | 1457554909
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Entity Type | Individual
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Provider Name | TRAVIS EUGENE MACKENZIE OT
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Gender | Male
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Dates
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Enumeration Date | 06/11/2007
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Last Update Date | 07/02/2019
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Provider Practice Location Address
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Address Line | 1375 S COLUMBIA RD - ALTRU PERFORMANCE CENTER
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City | GRAND FORKS
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State | ND
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Zip | 58201
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Country | US
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Telephone | 701-780-5000
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Fax |
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Provider Business Mailing Address
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Address Line | 2401 DEMERS AVE
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City | GRAND FORKS
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State | ND
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Zip | 58201
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Country | US
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Telephone | 701-780-1891
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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 | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 940
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License Number State | ND
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