1073113205 NPI number — DR. TRAVIS SCOTT KOHNHORST PHARMD

Table of content: DR. TRAVIS SCOTT KOHNHORST PHARMD (NPI 1073113205)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073113205 NPI number — DR. TRAVIS SCOTT KOHNHORST PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOHNHORST
Provider First Name:
TRAVIS
Provider Middle Name:
SCOTT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
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:
1073113205
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4601 17TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79416-5705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-928-6278
Provider Business Mailing Address Fax Number:
806-894-7599

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
407 E HIGHWAY 114
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEVELLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79336-2629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-894-7583
Provider Business Practice Location Address Fax Number:
806-894-7599
Provider Enumeration Date:
10/27/2020

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: 183500000X , with the licence number:  39358 , 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)





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