Healthcare Provider Details

I. General information

NPI: 1720540214
Provider Name (Legal Business Name): AXIAL MEDICAL CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5190 NW 167TH ST STE 306
MIAMI LAKES FL
33014-6338
US

IV. Provider business mailing address

5190 NW 167TH ST STE 306
MIAMI LAKES FL
33014-6338
US

V. Phone/Fax

Practice location:
  • Phone: 305-627-5557
  • Fax:
Mailing address:
  • Phone: 305-627-5557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: WENDY PELEGRIN
Title or Position: ADMINISTRATOR
Credential: RN, BSN
Phone: 305-627-5557