Provider Demographics
NPI:1720605942
Name:AXIAL PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:AXIAL PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BISI
Authorized Official - Middle Name:N
Authorized Official - Last Name:WILTON-WADDELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:310-493-1356
Mailing Address - Street 1:7247 TAGGART PL
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-1868
Mailing Address - Country:US
Mailing Address - Phone:310-493-1356
Mailing Address - Fax:323-395-5403
Practice Address - Street 1:7247 TAGGART PL
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-1868
Practice Address - Country:US
Practice Address - Phone:310-493-1356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-03
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty