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General NPI Number Information
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NPI Number | 1710104807
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Entity Type | Organization
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Legal Business Name | AXIS RESIDENTIAL TREATMENT LLC
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Dates
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Enumeration Date | 04/19/2007
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Last Update Date | 07/31/2008
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Provider Practice Location Address
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Address Line | 75450 FAIRWAY DR
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City | INDIAN WELLS
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State | CA
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Zip | 92210-8421
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Country | US
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Telephone | 760-469-8275
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Fax | 760-346-8032
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Provider Business Mailing Address
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Address Line | 75450 FAIRWAY DR
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City | INDIAN WELLS
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State | CA
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Zip | 92210-8421
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Country | US
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Telephone | 760-469-8275
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Fax | 760-346-8032
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Authorized Official
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Title or Position | CEO
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Name | BRAD T KEITH
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Credential | CCDC CAD CA
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Telephone | 310-435-6298
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | 330082AP
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License Number State | CA
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