Provider Demographics
NPI:1699432807
Name:AXIS SPORTS MEDICINE, LLC
Entity type:Organization
Organization Name:AXIS SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-406-2559
Mailing Address - Street 1:PO BOX 5584
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:CO
Mailing Address - Zip Code:80443-5584
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1143 CAPITOL ST UNIT 102B
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:CO
Practice Address - Zip Code:81631-5000
Practice Address - Country:US
Practice Address - Phone:970-328-4566
Practice Address - Fax:970-328-5591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000148002Medicaid