=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720521040
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGAVE PHYSICAL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2016
-----------------------------------------------------
Last Update Date | 12/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 191 SWANSON AVE #102
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86403-6699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-855-7880
-----------------------------------------------------
Fax | 928-855-7881
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 191 SWANSON AVE #102
-----------------------------------------------------
City | LAKE HAVASU CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86403-6699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-855-7880
-----------------------------------------------------
Fax | 928-855-7881
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRETT QUALLS
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 928-855-7880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------