Provider Demographics
NPI:1710104807
Name:AXIS RESIDENTIAL TREATMENT LLC
Entity Type:Organization
Organization Name:AXIS RESIDENTIAL TREATMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:T
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:CCDC CAD CA
Authorized Official - Phone:310-435-6298
Mailing Address - Street 1:75450 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:INDIAN WELLS
Mailing Address - State:CA
Mailing Address - Zip Code:92210-8421
Mailing Address - Country:US
Mailing Address - Phone:760-469-8275
Mailing Address - Fax:760-346-8032
Practice Address - Street 1:75450 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:INDIAN WELLS
Practice Address - State:CA
Practice Address - Zip Code:92210-8421
Practice Address - Country:US
Practice Address - Phone:760-469-8275
Practice Address - Fax:760-346-8032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA330082AP324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility