Provider Demographics
NPI:1285383463
Name:MCCLENDON, TRAVIS LAMAR
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:LAMAR
Last Name:MCCLENDON
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 1:1226 GOINS RD
Mailing Address - Street 2:
Mailing Address - City:WRIGHTSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31096-6104
Mailing Address - Country:US
Mailing Address - Phone:478-232-3454
Mailing Address - Fax:
Practice Address - Street 1:2118 W ELM ST
Practice Address - Street 2:
Practice Address - City:WRIGHTSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31096-5157
Practice Address - Country:US
Practice Address - Phone:478-292-7533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor