Healthcare Provider Details

I. General information

NPI: 1962435966
Provider Name (Legal Business Name): AGAVE CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3818 E INDIAN SCHOOL RD
PHOENIX AZ
85018-5235
US

IV. Provider business mailing address

3818 E INDIAN SCHOOL RD
PHOENIX AZ
85018-5235
US

V. Phone/Fax

Practice location:
  • Phone: 602-956-8736
  • Fax:
Mailing address:
  • Phone: 602-956-8736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberAZ5355
License Number StateAZ

VIII. Authorized Official

Name: DR. PAUL WILLIAM VAN BERKEL
Title or Position: OWNER
Credential: D.C.
Phone: 602-956-8736