Provider Demographics
NPI:1902497001
Name:AGAVE CARE HOME OF SCOTTSDALE LLC
Entity Type:Organization
Organization Name:AGAVE CARE HOME OF SCOTTSDALE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DINA
Authorized Official - Middle Name:BATA
Authorized Official - Last Name:ARGUILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-795-6107
Mailing Address - Street 1:4833 E MARCONI AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-1634
Mailing Address - Country:US
Mailing Address - Phone:602-795-6107
Mailing Address - Fax:602-801-3543
Practice Address - Street 1:4833 E MARCONI AVE
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-1634
Practice Address - Country:US
Practice Address - Phone:602-795-6107
Practice Address - Fax:602-801-3543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ287774Medicaid