1619971025 NPI number — TRAVIS MEDICAL SALES CORPORATION

Table of content: (NPI 1619971025)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619971025 NPI number — TRAVIS MEDICAL SALES CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRAVIS MEDICAL SALES 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:
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:
1619971025
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5959 SHALLOWFORD RD STE 443
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37421-2245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-756-2268
Provider Business Mailing Address Fax Number:
423-362-5413

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8 N 21ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEMPLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76504-2532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-458-4589
Provider Business Practice Location Address Fax Number:
512-454-9521
Provider Enumeration Date:
06/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MATUKEWICZ
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
423-756-2268

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BC3200X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1619971025 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 514771 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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