Provider Demographics
NPI:1396297669
Name:AXIOM REHABILITATION
Entity type:Organization
Organization Name:AXIOM REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MOURA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-388-8866
Mailing Address - Street 1:155 CRANES ROOST BLVD
Mailing Address - Street 2:SUITE 2090
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-3468
Mailing Address - Country:US
Mailing Address - Phone:407-388-8866
Mailing Address - Fax:407-494-0644
Practice Address - Street 1:155 CRANES ROOST BLVD
Practice Address - Street 2:SUITE 2090
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-3468
Practice Address - Country:US
Practice Address - Phone:407-388-8866
Practice Address - Fax:407-494-0644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19593261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy