Provider Demographics
NPI:1316277809
Name:AXIOM MEDICAL, LLC
Entity type:Organization
Organization Name:AXIOM MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:F
Authorized Official - Last Name:FAHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-867-9479
Mailing Address - Street 1:390 W COLCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5864
Mailing Address - Country:US
Mailing Address - Phone:208-939-8079
Mailing Address - Fax:
Practice Address - Street 1:390 W COLCHESTER DR
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5864
Practice Address - Country:US
Practice Address - Phone:208-939-8079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-05
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies