MEDICARE: TRAVIS DAIGNAULT

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	101Y00000X	Counselor
2	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1811342249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRAVIS DAIGNAULT

Provider Business Mailing Address
First Line	:	6013 S REDWOOD RD
Second Line	:
City	:	TAYLORSVILLE
State	:	UT
Zip	:	84123-5220
Country	:	US
Telephone Number	:	801-255-5131
Fax Number	:	801-255-5131

Provider Business Practice Location Address
First Line	:	1870 N MAIN ST
Second Line	:	SUITE 102
City	:	CEDAR CITY
State	:	UT
Zip	:	84721-7744
Country	:	US
Telephone Number	:	801-255-5131
Fax Number	:	801-255-5131

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2016
Last Update Date	:	05/04/2016

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Directions to “ TRAVIS DAIGNAULT ” Practice Location

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