Provider Demographics
NPI:1699136358
Name:AXTELL CLINIC PA
Entity type:Organization
Organization Name:AXTELL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MANDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-283-2800
Mailing Address - Street 1:700 MEDICAL CENTER DRIVE SUITE 210
Mailing Address - Street 2:SUITE 210B
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114
Mailing Address - Country:US
Mailing Address - Phone:316-804-4705
Mailing Address - Fax:
Practice Address - Street 1:1715 MEDICAL PARKWAY
Practice Address - Street 2:SUITE 110B
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-9013
Practice Address - Country:US
Practice Address - Phone:316-283-2800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-09
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS0562380002Medicare NSC
KS003785Medicare PIN