Provider Demographics
NPI:1972975456
Name:AXTELL EYE CENTER LLC
Entity Type:Organization
Organization Name:AXTELL EYE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALO
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:316-283-2800
Mailing Address - Street 1:700 MEDICAL CENTER DR STE 210
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-9017
Mailing Address - Country:US
Mailing Address - Phone:316-283-2800
Mailing Address - Fax:316-283-3575
Practice Address - Street 1:700 MEDICAL CENTER DR STE 210
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-9017
Practice Address - Country:US
Practice Address - Phone:316-283-2800
Practice Address - Fax:316-283-3575
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AXTELL CLINIC PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-23
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-21695207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKA3820Medicare PIN
0562380002Medicare NSC
KS100003230AMedicaid
003785Medicare PIN