Provider Demographics
NPI:1104307842
Name:MOULTON, TRAVIS
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:MOULTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 FAIRFIELD ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04963-5220
Mailing Address - Country:US
Mailing Address - Phone:207-660-7363
Mailing Address - Fax:
Practice Address - Street 1:708 FAIRFIELD ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:ME
Practice Address - Zip Code:04963-5220
Practice Address - Country:US
Practice Address - Phone:207-660-7363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME03192015374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME$$$$$$$$$Medicaid