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General NPI Number Information
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NPI Number | 1851496939
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Entity Type | Organization
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Legal Business Name | CLINICA AGAVE CLINIC
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Dates
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Enumeration Date | 09/14/2006
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Last Update Date | 03/23/2010
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Provider Practice Location Address
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Address Line | 425 SIGMAN ROAD SUITE #109
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City | CONYERS
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State | GA
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Zip | 30012
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Country | US
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Telephone | 678-413-2026
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Fax | 678-413-2030
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Provider Business Mailing Address
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Address Line | 425 SIGMAN ROAD SUITE #109
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City | CONYERS
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State | GA
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Zip | 30012
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Country | US
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Telephone | 678-413-2026
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Fax | 678-413-2030
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Authorized Official
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Title or Position | OWNER/ADMINISTRATOR
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Name | JUDITH TAKEM CHABOT
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Credential | FNP-C
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Telephone | 678-413-2026
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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