Healthcare Provider Details

I. General information

NPI: 1518682038
Provider Name (Legal Business Name): AXIS ALLIANCE NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2022
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 W HUNDRED RD STE C
CHESTER VA
23831-1746
US

IV. Provider business mailing address

5519 BACKWATER TER
NORTH CHESTERFIELD VA
23234-7732
US

V. Phone/Fax

Practice location:
  • Phone: 804-533-2293
  • Fax: 804-597-0219
Mailing address:
  • Phone: 804-687-8558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KYMBERLI DIAMOND
Title or Position: CEO
Credential: LPC
Phone: 804-687-8558