MEDICARE: AXIS MENTAL HEALTH, LLC

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	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1144747940
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AXIS MENTAL HEALTH, LLC

Provider Business Mailing Address
First Line	:	1230 W SANTA ANA BLVD
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92703-3835
Country	:	US
Telephone Number	:	714-582-2714
Fax Number	:

Provider Business Practice Location Address
First Line	:	1230 W SANTA ANA BLVD
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92703-3835
Country	:	US
Telephone Number	:	949-501-5979
Fax Number	:

Authorized Official
Title or Position	:	SUPERVISOR
Name	:	DARRYLE MACKELVEY
Credential	:
Telephone Number	:	714-948-6086

Provider Enumeration Date	:	08/23/2017
Last Update Date	:	10/28/2019

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