Provider Demographics
NPI:1245391945
Name:SAGE CAMPIONE, DCPA
Entity Type:Organization
Organization Name:SAGE CAMPIONE, DCPA
Other - Org Name:AXIS CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:KOTILA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:813-643-1242
Mailing Address - Street 1:330 PAULS DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4801
Mailing Address - Country:US
Mailing Address - Phone:813-643-1242
Mailing Address - Fax:813-643-1246
Practice Address - Street 1:330 PAULS DR
Practice Address - Street 2:SUITE 102
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4801
Practice Address - Country:US
Practice Address - Phone:813-643-1242
Practice Address - Fax:813-643-1246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9719111N00000X
FLCH8164111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU-85417Medicare UPIN
FLK7478Medicare PIN