Provider Demographics
NPI:1366074312
Name:AXIS SUPPORT SERVICES
Entity type:Organization
Organization Name:AXIS SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:OLABODE
Authorized Official - Middle Name:G
Authorized Official - Last Name:LONGE
Authorized Official - Suffix:
Authorized Official - Credentials:CISA, CA
Authorized Official - Phone:109-298-4494
Mailing Address - Street 1:9721 LUGUNA RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-3769
Mailing Address - Country:US
Mailing Address - Phone:443-226-3289
Mailing Address - Fax:
Practice Address - Street 1:9721 LUGUNA RD
Practice Address - Street 2:
Practice Address - City:MIDDLE RIVER
Practice Address - State:MD
Practice Address - Zip Code:21220-3769
Practice Address - Country:US
Practice Address - Phone:443-226-3289
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities