Provider Demographics
NPI:1821443474
Name:AXISPRO PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:AXISPRO PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MACIEJ
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLIK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:321-514-2844
Mailing Address - Street 1:645 NEWPORT DR
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-4030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 N WICKHAM RD
Practice Address - Street 2:SUITE 103
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8628
Practice Address - Country:US
Practice Address - Phone:321-802-3130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-02
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 27353261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy