Provider Demographics
NPI:1780137455
Name:AXIOM
Entity type:Organization
Organization Name:AXIOM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OTR/L
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:FULMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-252-1021
Mailing Address - Street 1:2400 RIVER TREE CIR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-8332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2400 RIVER TREE CIR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-8332
Practice Address - Country:US
Practice Address - Phone:407-252-1021
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-29
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT1201320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities