Provider Demographics
NPI:1861153579
Name:AGAVE ADULT MEDICAL CARE, LLC
Entity type:Organization
Organization Name:AGAVE ADULT MEDICAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CHASCITY
Authorized Official - Middle Name:
Authorized Official - Last Name:MONROE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:315-717-7898
Mailing Address - Street 1:70 BELL ROCK PLZ STE C
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86351-9066
Mailing Address - Country:US
Mailing Address - Phone:928-284-2658
Mailing Address - Fax:928-284-2469
Practice Address - Street 1:70 BELL ROCK PLZ STE C
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86351-9066
Practice Address - Country:US
Practice Address - Phone:315-717-7898
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-05
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty