Basic Information
Provider Information
NPI: 1114144359
EntityType: 2
ReplacementNPI:  
OrganizationName: AXIS COMMUNITY HEALTH INC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: AXIS COMMUNITY HEALTH
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4361 RAILROAD AVE
Address2:  
City: PLEASANTON
State: CA
PostalCode: 945666611
CountryCode: US
TelephoneNumber: 9254621755
FaxNumber:  
Practice Location
Address1: 4361 RAILROAD AVE
Address2:  
City: PLEASANTON
State: CA
PostalCode: 945666611
CountryCode: US
TelephoneNumber: 9254621755
FaxNumber:  
Other Information
ProviderEnumerationDate: 04/19/2007
LastUpdateDate: 03/11/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: COMPTON
AuthorizedOfficialFirstName: SUE
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CEO
AuthorizedOfficialTelephone: 9254621755
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MRS.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 03/11/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261Q00000XBCP11593FCAN Ambulatory Health Care FacilitiesClinic/Center 
261QF0400XA0610721CAY Ambulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)

ID Information
IDTypeStateIssuerDescription
BCP11593F05CA MEDICAID


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