Healthcare Provider Details

I. General information

NPI: 1396297669
Provider Name (Legal Business Name): AXIOM REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 CRANES ROOST BLVD SUITE 2090
ALTAMONTE SPRINGS FL
32701-3468
US

IV. Provider business mailing address

155 CRANES ROOST BLVD SUITE 2090
ALTAMONTE SPRINGS FL
32701-3468
US

V. Phone/Fax

Practice location:
  • Phone: 407-388-8866
  • Fax: 407-494-0644
Mailing address:
  • Phone: 407-388-8866
  • Fax: 407-494-0644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number19593
License Number StateFL

VIII. Authorized Official

Name: DUSTIN P MOURA
Title or Position: MANAGING PARTNER
Credential:
Phone: 407-388-8866