Healthcare Provider Details

I. General information

NPI: 1669090510
Provider Name (Legal Business Name): AXIA INTERNATIONAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2020
Last Update Date: 07/08/2020
Certification Date: 07/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 S HIGHWAY 89
BOUNTIFUL UT
84010-8517
US

IV. Provider business mailing address

3401 S HIGHWAY 89
BOUNTIFUL UT
84010-8517
US

V. Phone/Fax

Practice location:
  • Phone: 385-355-7600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. SAUL LEAL
Title or Position: PRINCIPAL
Credential:
Phone: 385-355-7600