MEDICARE: AXIS BEHAVIORAL HEALTH, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1497217699
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AXIS BEHAVIORAL HEALTH, INC

Provider Business Mailing Address
First Line	:	740 12TH AVE S
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56301-4219
Country	:	US
Telephone Number	:	612-644-3912
Fax Number	:

Provider Business Practice Location Address
First Line	:	740 12TH AVE S
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56301-4219
Country	:	US
Telephone Number	:	612-644-3912
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BOSTEYA ABDULAHI FARAH
Credential	:
Telephone Number	:	612-644-3912

Provider Enumeration Date	:	04/05/2019
Last Update Date	:	04/05/2019

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Directions to “AXIS BEHAVIORAL HEALTH, INC ” Practice Location

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