Provider Demographics
NPI:1518905512
Name:AXIS CLINIC PC
Entity Type:Organization
Organization Name:AXIS CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:M
Authorized Official - Last Name:NORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L, CHT
Authorized Official - Phone:701-792-2947
Mailing Address - Street 1:1451 44TH AVE S STE 120D
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-3434
Mailing Address - Country:US
Mailing Address - Phone:701-732-2947
Mailing Address - Fax:701-732-2945
Practice Address - Street 1:1451 44TH AVE S STE 120D
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-3434
Practice Address - Country:US
Practice Address - Phone:701-732-2947
Practice Address - Fax:701-732-4945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND25225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
01042277OtherPREFERRED ONE
2476885OtherUNITED HEALTH CARE
MN700A8AXOtherBLUE CROSS BLUE SHIELD
115081OtherHEALTH PARTNERS
ND50900Medicaid
ND26105OtherBLUE CROSS BLUE SHIELD
ND54900Medicaid
MN548G3AXOtherBLUE CROSS BLUE SHIELD
ND50900Medicaid
5335800001Medicare NSC
MN700A8AXOtherBLUE CROSS BLUE SHIELD
DD9269Medicare PIN