Healthcare Provider Details

I. General information

NPI: 1134948458
Provider Name (Legal Business Name): AXIS SPINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2024
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1519 3RD ST SE STE 101
PUYALLUP WA
98372-3742
US

IV. Provider business mailing address

1101 N 39TH CT
RENTON WA
98056-1624
US

V. Phone/Fax

Practice location:
  • Phone: 909-659-1852
  • Fax:
Mailing address:
  • Phone: 909-659-1852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KENNETH NWOSU
Title or Position: SPINE SURGEON
Credential: MD
Phone: 909-659-1852