Healthcare Provider Details

I. General information

NPI: 1114189446
Provider Name (Legal Business Name): AXIS INCORPORATED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2008
Last Update Date: 02/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1816 SEA SHELL CT
WINDSOR CO
80550
US

IV. Provider business mailing address

1816 SEA SHELL CT
WINDSOR CO
80550
US

V. Phone/Fax

Practice location:
  • Phone: 970-818-6190
  • Fax: 970-460-0581
Mailing address:
  • Phone: 970-818-6190
  • Fax: 970-460-0581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1512
License Number StateCO

VIII. Authorized Official

Name: MRS. MAROMI DHUPAR-SAKURAI
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 970-818-6190