Provider Demographics
NPI:1194175257
Name:BENN, TRAVIS (PT)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:BENN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:706-494-3008
Practice Address - Street 1:6262 VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-3540
Practice Address - Country:US
Practice Address - Phone:706-324-6661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-20
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012374208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation