1740316793 NPI number — TRAVIS J TESSENDORF D.C. P.C.

Table of content: (NPI 1740316793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740316793 NPI number — TRAVIS J TESSENDORF D.C. P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRAVIS J TESSENDORF D.C. P.C.
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:
6
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:
1740316793
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 727
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68602-0727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-564-0193
Provider Business Mailing Address Fax Number:
402-564-0179

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2360 26TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68601-2527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-564-0193
Provider Business Practice Location Address Fax Number:
402-564-0179
Provider Enumeration Date:
02/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TESSENDORF
Authorized Official First Name:
TRAVIS
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
402-564-0193

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  1197 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 350049151 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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