Healthcare Provider Details

I. General information

NPI: 1477478923
Provider Name (Legal Business Name): BLUE AGAVE FUNCTIONAL MEDICINE LEANDER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 S HIGHWAY 183
LEANDER TX
78641-1834
US

IV. Provider business mailing address

311 S HIGHWAY 183
LEANDER TX
78641-1834
US

V. Phone/Fax

Practice location:
  • Phone: 830-491-4040
  • Fax: 830-584-0995
Mailing address:
  • Phone: 830-491-4040
  • Fax: 830-584-0995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT KNEPPER
Title or Position: OWNER
Credential:
Phone: 830-491-4040