=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104579093
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AXEDIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2022
-----------------------------------------------------
Last Update Date | 01/31/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 818 N DOHENY DR APT 206
-----------------------------------------------------
City | WEST HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90069-4857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-683-2040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 818 N DOHENY DR APT 206
-----------------------------------------------------
City | WEST HOLLYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90069-4857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | YOAN ESEBAG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 323-683-2040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------