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General NPI Number Information
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NPI Number | 1851869234
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Entity Type | Organization
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Legal Business Name | BLUE AGAVE WOUND CARE SOLUTIONS LLC
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Dates
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Enumeration Date | 11/05/2018
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Last Update Date | 11/05/2018
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Provider Practice Location Address
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Address Line | 10109 LAKE CREEK PKWY UNIT 170434
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City | AUSTIN
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State | TX
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Zip | 78717-0119
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Country | US
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Telephone | 844-275-3822
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 170434
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City | AUSTIN
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State | TX
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Zip | 78717-0027
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Country | US
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Telephone | 844-275-3822
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Fax |
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Authorized Official
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Title or Position | MEMBER LLC
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Name | RICHARD CARNEY
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Credential |
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Telephone | 619-568-6800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WH0200X
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Taxonomy Name | Home Health Registered Nurse
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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 | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 364SH0200X
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Taxonomy Name | Home Health Clinical Nurse Specialist
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 374U00000X
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Taxonomy Name | Home Health Aide
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 163WW0000X
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Taxonomy Name | Wound Care Registered Nurse
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License Number |
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License Number State |
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