Provider Demographics
NPI:1710367875
Name:AXIS CHIROPRACTIC AND SPORTS REHABILITATION CLINIC LLC
Entity Type:Organization
Organization Name:AXIS CHIROPRACTIC AND SPORTS REHABILITATION CLINIC LLC
Other - Org Name:AXIS CHIROPRACTIC & SPORTS REHAB
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:H
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:318-773-1398
Mailing Address - Street 1:3215 E MILTON AVE
Mailing Address - Street 2:SUITES 7-8
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592-5546
Mailing Address - Country:US
Mailing Address - Phone:337-573-9009
Mailing Address - Fax:855-452-4557
Practice Address - Street 1:3215 E MILTON AVE
Practice Address - Street 2:SUITES 7-8
Practice Address - City:YOUNGSVILLE
Practice Address - State:LA
Practice Address - Zip Code:70592-5546
Practice Address - Country:US
Practice Address - Phone:337-573-9009
Practice Address - Fax:855-452-4557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-04
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1671111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty