Provider Demographics
NPI:1104535012
Name:EDEN, TRAVIS COLTON (RDN)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:COLTON
Last Name:EDEN
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5407
Mailing Address - Country:US
Mailing Address - Phone:918-744-3624
Mailing Address - Fax:
Practice Address - Street 1:10301 N 98TH EAST AVE
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-7883
Practice Address - Country:US
Practice Address - Phone:479-787-0811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2512133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered