Provider Demographics
NPI:1295027399
Name:AGAVE GROUP, LLC
Entity Type:Organization
Organization Name:AGAVE GROUP, LLC
Other - Org Name:OCOTILLO PRESERVE ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEJANDRO
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIETO
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED CAREGIVER
Authorized Official - Phone:520-444-3354
Mailing Address - Street 1:9777 E OCOTILLO RIM TRL
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641-2142
Mailing Address - Country:US
Mailing Address - Phone:520-444-3354
Mailing Address - Fax:
Practice Address - Street 1:9777 E OCOTILLO RIM TRL
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:AZ
Practice Address - Zip Code:85641-2142
Practice Address - Country:US
Practice Address - Phone:520-444-3354
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-06
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL7851H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility