Provider Demographics
NPI:1275073488
Name:AGAPE ADVANCED INTEGRATIVE MEDICINE LLC
Entity Type:Organization
Organization Name:AGAPE ADVANCED INTEGRATIVE MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAVROOKAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-687-0616
Mailing Address - Street 1:4837 N DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334-3928
Mailing Address - Country:US
Mailing Address - Phone:561-567-0626
Mailing Address - Fax:561-865-0174
Practice Address - Street 1:4837 N DIXIE HWY
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33334-3928
Practice Address - Country:US
Practice Address - Phone:561-567-0626
Practice Address - Fax:561-865-0174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0618128360001261QR0405X
FL0601324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder