1659302396 NPI number — TRAVIS CORPORATION

Table of content: (NPI 1659302396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659302396 NPI number — TRAVIS CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRAVIS CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PEOPLE CARE CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659302396
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1705 COLUMBUS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROXBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-516-5150
Provider Business Mailing Address Fax Number:
617-442-6915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1705 COLUMBUS AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROXBURY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-516-5150
Provider Business Practice Location Address Fax Number:
617-442-6915
Provider Enumeration Date:
07/05/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BIRD
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
617-441-1770

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  4211 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)