Provider Demographics
NPI:1326427725
Name:AGNITUS LLC
Entity Type:Organization
Organization Name:AGNITUS LLC
Other - Org Name:AGNITUS THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:SLP-CCC
Authorized Official - Phone:813-431-1153
Mailing Address - Street 1:16350 BRUCE B DOWNS BLVD
Mailing Address - Street 2:SUITE 46124
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33646-9001
Mailing Address - Country:US
Mailing Address - Phone:813-309-9398
Mailing Address - Fax:813-333-4240
Practice Address - Street 1:1153 HELMSDALE DR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-3914
Practice Address - Country:US
Practice Address - Phone:813-309-9398
Practice Address - Fax:813-333-4240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-19
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA2364251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL892070200Medicaid
FLIJ645AMedicare PIN