Healthcare Provider Details

I. General information

NPI: 1598553331
Provider Name (Legal Business Name): AGAVE MEDICAL CA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2025
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16397 ROAD 37
MADERA CA
93636-8224
US

IV. Provider business mailing address

359 5TH ST UNIT 3
JERSEY CITY NJ
07302-2329
US

V. Phone/Fax

Practice location:
  • Phone: 929-209-6109
  • Fax:
Mailing address:
  • Phone: 929-209-6109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ORI FRUHAUF
Title or Position: OWNER
Credential:
Phone: 551-302-1794