MEDICARE: AXIOM LABS LLC

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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1982297768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AXIOM LABS LLC

Provider Business Mailing Address
First Line	:	801 BEVILLE RD
Second Line	:
City	:	SOUTH DAYTONA
State	:	FL
Zip	:	32119-1860
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	801 BEVILLE RD
Second Line	:
City	:	SOUTH DAYTONA
State	:	FL
Zip	:	32119-1860
Country	:	US
Telephone Number	:	352-213-4295
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NITIN AGGARWAL
Credential	:
Telephone Number	:	352-213-4295

Provider Enumeration Date	:	02/12/2021
Last Update Date	:	02/12/2021

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