Healthcare Provider Details

I. General information

NPI: 1740843697
Provider Name (Legal Business Name): AXIAL-IM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3898 W INNOVATION DR STE B
RIVERTON UT
84065-6038
US

IV. Provider business mailing address

PO BOX 95411
SOUTH JORDAN UT
84095-0411
US

V. Phone/Fax

Practice location:
  • Phone: 801-302-0660
  • Fax: 801-302-2239
Mailing address:
  • Phone: 801-210-2776
  • Fax: 801-972-5707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MOLLIE S WILSON
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 913-499-9885