=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891222907
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRAVIS MEDICAL SALES CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2017
-----------------------------------------------------
Last Update Date | 03/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12402 SLIDE RD BLDG 4 STE 401
-----------------------------------------------------
City | LUBBOCK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79424-8323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-701-5053
-----------------------------------------------------
Fax | 806-641-2960
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5959 SHALLOWFORD RD STE 443
-----------------------------------------------------
City | CHATTANOOGA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37421-2245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-756-2268
-----------------------------------------------------
Fax | 423-362-5413
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | JEFFREY MATUKEWICZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-756-2268
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------