Provider Demographics
NPI:1912348822
Name:AXTELL, ISAAC (LAC)
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:
Last Name:AXTELL
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 DALTON ST
Mailing Address - Street 2:APT. B
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-7311
Mailing Address - Country:US
Mailing Address - Phone:207-395-6101
Mailing Address - Fax:
Practice Address - Street 1:9 GETCHELL ST STE A
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-6109
Practice Address - Country:US
Practice Address - Phone:207-395-6101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-09
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEACU426171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist