Healthcare Provider Details

I. General information

NPI: 1922720333
Provider Name (Legal Business Name): AGAPE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 W 24TH ST STE B
YUMA AZ
85364-8877
US

IV. Provider business mailing address

2140 W 24TH ST STE B
YUMA AZ
85364-8877
US

V. Phone/Fax

Practice location:
  • Phone: 928-459-3400
  • Fax: 928-459-2077
Mailing address:
  • Phone: 928-503-4060
  • Fax: 928-459-2077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN ERNEST WILLIAMS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 928-459-3400