1033670245 NPI number — TRAVIS CASILLAS NNP-BC

Table of content: TRAVIS CASILLAS NNP-BC (NPI 1033670245)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033670245 NPI number — TRAVIS CASILLAS NNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASILLAS
Provider First Name:
TRAVIS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NNP-BC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1033670245
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2825 CHATSWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76262-3473
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1935 MEDICAL DISTRICT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75235-7701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-424-4537
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/29/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WN0002X , with the licence number:  833654 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LN0005X , with the licence number: AP141365 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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