=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073719043
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGAVE FAMILY HEALTH, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2007
-----------------------------------------------------
Last Update Date | 10/19/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3420 S MERCY RD 113
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85297-0419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-219-3346
-----------------------------------------------------
Fax | 480-219-3652
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3420 S MERCY RD 113
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85297-0419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-219-3346
-----------------------------------------------------
Fax | 480-219-3652
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MOLLY FINLEY RIVIEZZO
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 480-219-3346
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 4457
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------