Provider Demographics
NPI:1134948458
Name:AXIS SPINE LLC
Entity type:Organization
Organization Name:AXIS SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPINE SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:NWOSU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-659-1852
Mailing Address - Street 1:1101 N 39TH CT
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98056-1624
Mailing Address - Country:US
Mailing Address - Phone:909-659-1852
Mailing Address - Fax:
Practice Address - Street 1:1519 3RD ST SE STE 101
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3742
Practice Address - Country:US
Practice Address - Phone:909-659-1852
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty