=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609698455
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGAPE LIFE MULTICULTURAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2024
-----------------------------------------------------
Last Update Date | 10/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 VIRGINIA ST STE F
-----------------------------------------------------
City | GRAND PRAIRIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75051-3796
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-862-5756
-----------------------------------------------------
Fax | 469-332-3118
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1024 FAIR OAKS DR
-----------------------------------------------------
City | GRAND PRAIRIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75052-2718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-862-5756
-----------------------------------------------------
Fax | 469-332-3118
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KARAN STAGGERS
-----------------------------------------------------
Credential | NURSE PRACTITIONER
-----------------------------------------------------
Telephone | 214-862-5756
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------