Healthcare Provider Details

I. General information

NPI: 1417397928
Provider Name (Legal Business Name): AGAVE HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2013
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2551 COORS BOULEVARD NORTHWEST
ALBUQUERQUE NM
87120
US

IV. Provider business mailing address

2551 COORS BLVD NW
ALBUQUERQUE NM
87120-1213
US

V. Phone/Fax

Practice location:
  • Phone: 602-285-4200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number3454
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number3454
License Number StateNM

VIII. Authorized Official

Name: MS. CINDY MONZON
Title or Position: HR
Credential: MBA, MS
Phone: 602-285-4239