Healthcare Provider Details

I. General information

NPI: 1699136358
Provider Name (Legal Business Name): AXTELL CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2016
Last Update Date: 07/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 MEDICAL PARKWAY SUITE 110B
NEWTON KS
67114-9013
US

IV. Provider business mailing address

700 MEDICAL CENTER DRIVE SUITE 210 SUITE 210B
NEWTON KS
67114
US

V. Phone/Fax

Practice location:
  • Phone: 316-283-2800
  • Fax:
Mailing address:
  • Phone: 316-804-4705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MANDY L HINER
Title or Position: ADMINISTRATOR
Credential:
Phone: 316-283-2800