Basic Information
Provider Information | |||||||||
NPI: | 1912594243 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AXES PHYSICAL THERAPY I, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4273 KEATON CROSSING BLVD | ||||||||
Address2: |   | ||||||||
City: | O FALLON | ||||||||
State: | MO | ||||||||
PostalCode: | 633688220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6362064225 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 21 SILO DR | ||||||||
Address2: |   | ||||||||
City: | UNION | ||||||||
State: | MO | ||||||||
PostalCode: | 630844917 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6366494131 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/21/2020 | ||||||||
LastUpdateDate: | 12/21/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TEEPE | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
AuthorizedOfficialTelephone: | 3147642230 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | AXES PHYSICAL THERAPY, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/21/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X |   |   | Y |   | Suppliers | Prosthetic/Orthotic Supplier |   |
No ID Information.