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General NPI Number Information
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NPI Number | 1982046975
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Entity Type | Organization
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Legal Business Name | AGAVE CHIROPRACTIC, LLC
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Dates
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Enumeration Date | 07/19/2013
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Last Update Date | 07/30/2013
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Provider Practice Location Address
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Address Line | 3040 N 44TH ST SUITE 3
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City | PHOENIX
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State | AZ
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Zip | 85018-7225
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Country | US
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Telephone | 602-956-8736
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Fax | 602-956-8769
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Provider Business Mailing Address
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Address Line | 3040 N 44TH ST SUITE 3
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City | PHOENIX
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State | AZ
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Zip | 85018-7225
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Country | US
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Telephone | 602-956-8736
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Fax | 602-956-8769
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Authorized Official
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Title or Position | OWNER
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Name | DR. PAUL VAN BERKEL
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Credential | D.C.
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Telephone | 602-956-8736
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 5355
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License Number State | AZ
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