Provider Demographics
NPI:1972085371
Name:AXIS REJUVENATION LLC
Entity type:Organization
Organization Name:AXIS REJUVENATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DRAPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-953-5323
Mailing Address - Street 1:100 BOSA DR STE A
Mailing Address - Street 2:
Mailing Address - City:SAINT ROBERT
Mailing Address - State:MO
Mailing Address - Zip Code:65584-4833
Mailing Address - Country:US
Mailing Address - Phone:801-953-5323
Mailing Address - Fax:801-336-2256
Practice Address - Street 1:100 BOSA DR STE A
Practice Address - Street 2:
Practice Address - City:SAINT ROBERT
Practice Address - State:MO
Practice Address - Zip Code:65584-4833
Practice Address - Country:US
Practice Address - Phone:573-337-4568
Practice Address - Fax:573-336-2256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-31
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center