Healthcare Provider Details

I. General information

NPI: 1356033278
Provider Name (Legal Business Name): AGILE OCCUPATIONAL MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 05/22/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2524 H. DE LA ROSA SR. STREET
SOLEDAD CA
93960
US

IV. Provider business mailing address

3200 BRISTOL ST STE 600
COSTA MESA CA
92626-1810
US

V. Phone/Fax

Practice location:
  • Phone: 831-678-8899
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GREGORY MOORE
Title or Position: CEO
Credential:
Phone: 844-207-8321