Provider Demographics
NPI:1053082263
Name:AGAVE PHYSICIAN SERVICES LLC
Entity Type:Organization
Organization Name:AGAVE PHYSICIAN SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RHETT
Authorized Official - Middle Name:S
Authorized Official - Last Name:ANDERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-420-0077
Mailing Address - Street 1:1008 N 1100 E
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-2066
Mailing Address - Country:US
Mailing Address - Phone:801-420-0077
Mailing Address - Fax:
Practice Address - Street 1:3240 E UNION HILLS DR STE 145
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-2652
Practice Address - Country:US
Practice Address - Phone:602-855-3500
Practice Address - Fax:855-930-3500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative MedicineGroup - Single Specialty