Provider Demographics
NPI:1790328045
Name:AXIS PHYSIOTHERAPY INSTITUTE, LLC
Entity Type:Organization
Organization Name:AXIS PHYSIOTHERAPY INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/ PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:LEARY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, ATC
Authorized Official - Phone:850-499-9033
Mailing Address - Street 1:1646 PARKSIDE CIR
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-8706
Mailing Address - Country:US
Mailing Address - Phone:850-499-9033
Mailing Address - Fax:
Practice Address - Street 1:339 RACETRACK RD NW STE 18&20
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1538
Practice Address - Country:US
Practice Address - Phone:850-499-9033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-18
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty