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General NPI Number Information
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NPI Number | 1518657956
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Entity Type | Organization
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Legal Business Name | AGILE OCCUPATIONAL MEDICINE, PC
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Dates
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Enumeration Date | 05/09/2023
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Last Update Date | 12/23/2024
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Provider Practice Location Address
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Address Line | 420 W ACACIA ST
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City | STOCKTON
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State | CA
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Zip | 95203-2450
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Country | US
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Telephone | 209-273-1627
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Fax |
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Provider Business Mailing Address
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Address Line | 3200 BRISTOL ST STE 600
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City | COSTA MESA
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State | CA
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Zip | 92626-1810
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | GREGORY MOORE
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Credential |
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Telephone | 844-207-8321
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QX0100X
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Taxonomy Name | Occupational Medicine Clinic/Center
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License Number |
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License Number State |
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