Basic Information
| Provider Information | |||||||||
| NPI: | 1780993675 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOODY | ||||||||
| FirstName: | TRAVIS | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 THOMPSON AVE | ||||||||
| Address2: | |||||||||
| City: | WEST MEMPHIS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723013257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707024911 | ||||||||
| FaxNumber: | 8707026386 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 THOMPSON AVE | ||||||||
| Address2: | |||||||||
| City: | WEST MEMPHIS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723013257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707024911 | ||||||||
| FaxNumber: | 8707026386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2010 | ||||||||
| LastUpdateDate: | 09/27/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2272 | AR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.