Provider Demographics
NPI:1538606454
Name:ODOM, TRAVIS (MAT, LAT, ATC)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:ODOM
Suffix:
Gender:M
Credentials:MAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 SOUTH L.H.S. DRIVE
Mailing Address - Street 2:APT 103
Mailing Address - City:LUMBERTON
Mailing Address - State:TX
Mailing Address - Zip Code:77657
Mailing Address - Country:US
Mailing Address - Phone:904-316-1873
Mailing Address - Fax:
Practice Address - Street 1:103 S LHS DR
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:TX
Practice Address - Zip Code:77657-8601
Practice Address - Country:US
Practice Address - Phone:904-316-1873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXAT71172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program