Healthcare Provider Details

I. General information

NPI: 1982046975
Provider Name (Legal Business Name): AGAVE CHIROPRACTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2013
Last Update Date: 07/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 N 44TH ST SUITE 3
PHOENIX AZ
85018-7225
US

IV. Provider business mailing address

3040 N 44TH ST SUITE 3
PHOENIX AZ
85018-7225
US

V. Phone/Fax

Practice location:
  • Phone: 602-956-8736
  • Fax: 602-956-8769
Mailing address:
  • Phone: 602-956-8736
  • Fax: 602-956-8769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5355
License Number StateAZ

VIII. Authorized Official

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