Basic Information
| Provider Information | |||||||||
| NPI: | 1427651207 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAILEY | ||||||||
| FirstName: | AXEL | ||||||||
| MiddleName: | T | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9136 BELVEDERE DR | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762446214 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 12650 N BEACH ST STE 146 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762444253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8557827822 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2020 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-20-125770 | TX | Y |
No ID Information.