MEDICARE: AGAVE HEALTHCARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251G00000X	Community Based Hospice Care Agency

General Provider Information

NPI Number	:	1578220653
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGAVE HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	1008 N 1100 E
Second Line	:
City	:	PLEASANT GROVE
State	:	UT
Zip	:	84062-2066
Country	:	US
Telephone Number	:	602-855-3500
Fax Number	:	855-930-3500

Provider Business Practice Location Address
First Line	:	3240 E UNION HILLS DR STE 145
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85050-2652
Country	:	US
Telephone Number	:	602-855-3500
Fax Number	:	855-930-3500

Authorized Official
Title or Position	:	VP OF OPERATIONS
Name	:	CHRISTINE BOEHLER
Credential	:
Telephone Number	:	480-228-6202

Provider Enumeration Date	:	11/23/2021
Last Update Date	:	11/23/2021

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