Basic Information
| Provider Information | |||||||||
| NPI: | 1619971025 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRAVIS MEDICAL SALES CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 SHALLOWFORD RD STE 443 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374212245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237562268 | ||||||||
| FaxNumber: | 4233625413 | ||||||||
| Practice Location | |||||||||
| Address1: | 3201 INDUSTRIAL TER STE 130 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787587510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124584589 | ||||||||
| FaxNumber: | 5124549521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | MATUKEWICZ | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4237562268 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | TX | N | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment | 332BP3500X | TX | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 332BX2000X | TX | N | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies | 332B00000X | TX | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 016016004 | 05 | TX | MEDICAID | 016016006 | 05 | TX | MEDICAID | 514771 | 01 | TX | BCBS | OTHER | 016016003 | 05 | TX | MEDICAID |