Organization
AXOLOTL, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KEVIN CHEN (OWNER)
(618) 922-9952
Entity
Organization
Contact information
Practice address
130 E CLARK ST, HARRISBURG, IL 62946-2700
(618) 922-9952
Mailing address
1507 GLENEAGLE DR, MARION, IL 62959-5231
Taxonomy
Speciality
Code
Description
License number
State
261QE0700X
End-Stage Renal Disease (ESRD) Treatment Clinic/Center
Primary
—
—
Other
Enumeration date
05/18/2012
Last updated
05/18/2012
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