Healthcare Provider Details

I. General information

NPI: 1912456799
Provider Name (Legal Business Name): AXIOMHEALTH MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2016
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 SPRING CENTRE SOUTH BLVD STE 225
ALTAMONTE SPRINGS FL
32714-1991
US

IV. Provider business mailing address

1180 SPRING CENTRE SOUTH BLVD STE 225
ALTAMONTE SPRINGS FL
32714-1991
US

V. Phone/Fax

Practice location:
  • Phone: 407-494-0644
  • Fax: 407-494-0644
Mailing address:
  • Phone: 407-495-1165
  • Fax: 407-494-0644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DUSTIN PATRIC MOURA
Title or Position: REGISTERED AGENT
Credential: PTA
Phone: 407-388-8866