Provider Demographics
NPI:1033483615
Name:AXIS RESIDENTIAL TREATMENT - WEST
Entity Type:Organization
Organization Name:AXIS RESIDENTIAL TREATMENT - WEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:CADAC
Authorized Official - Phone:310-435-6298
Mailing Address - Street 1:4024 HURON AVE
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-4017
Mailing Address - Country:US
Mailing Address - Phone:310-838-3640
Mailing Address - Fax:
Practice Address - Street 1:4024 HURON AVE
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-4017
Practice Address - Country:US
Practice Address - Phone:310-838-3640
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190727AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility