Provider Demographics
NPI:1356026017
Name:AGTECH4VETS
Entity type:Organization
Organization Name:AGTECH4VETS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:IVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-569-2990
Mailing Address - Street 1:1883 WEST ROYAL HUNTE DR STE 200A
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-4000
Mailing Address - Country:US
Mailing Address - Phone:855-772-3374
Mailing Address - Fax:855-483-2771
Practice Address - Street 1:1883 WEST ROYAL HUNTE DR STE 200A
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-4000
Practice Address - Country:US
Practice Address - Phone:855-772-3374
Practice Address - Fax:855-483-2771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty