=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699254136
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEREMY RYAN TRAVIS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2018
-----------------------------------------------------
Last Update Date | 08/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1450 SHAIRE CENTER DR
-----------------------------------------------------
City | LENOIR
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28645-7565
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-728-6500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2845 WILL CLARKE PL
-----------------------------------------------------
City | MORGANTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28655-8571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-448-8292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | A6715
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------