MEDICARE: AXEDIA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1104579093
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AXEDIA

Provider Business Mailing Address
First Line	:	818 N DOHENY DR APT 206
Second Line	:
City	:	WEST HOLLYWOOD
State	:	CA
Zip	:	90069-4857
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	818 N DOHENY DR APT 206
Second Line	:
City	:	WEST HOLLYWOOD
State	:	CA
Zip	:	90069-4857
Country	:	US
Telephone Number	:	323-683-2040
Fax Number	:

Authorized Official
Title or Position	:	OWNER/AUTHORIZED OFFICIAL
Name	:	YOAN ESEBAG
Credential	:
Telephone Number	:	323-683-2040

Provider Enumeration Date	:	01/31/2022
Last Update Date	:	01/31/2022

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Directions to “AXEDIA ” Practice Location

Language	Start Address	Practice Location

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