MEDICARE: MASSVAX TRAVEL CLINIC L.L.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335V00000X	Portable X-ray and/or Other Portable Diagnostic Imaging Supplier

General Provider Information

NPI Number	:	1265450282
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MASSVAX TRAVEL CLINIC L.L.C.

Provider Business Mailing Address
First Line	:	113 PARKSIDE DR
Second Line	:
City	:	HEADLAND
State	:	AL
Zip	:	36345-1520
Country	:	US
Telephone Number	:	334-790-2260
Fax Number	:

Provider Business Practice Location Address
First Line	:	113 PARKSIDE DR
Second Line	:
City	:	HEADLAND
State	:	AL
Zip	:	36345-1520
Country	:	US
Telephone Number	:	334-790-2260
Fax Number	:

Authorized Official
Title or Position	:	RESPIRATORY THERAPIST
Name	:	MR. RAY CHARLES THOMPSON
Credential	:	R.R.T.
Telephone Number	:	334-790-2260

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	08/22/2020

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