Provider Demographics
NPI:1407091705
Name:CLINICA AGAVE CLINIC
Entity Type:Organization
Organization Name:CLINICA AGAVE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:T
Authorized Official - Last Name:CHABOT
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:404-447-3444
Mailing Address - Street 1:4434 JONESBORO RD
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30297-4313
Mailing Address - Country:US
Mailing Address - Phone:404-447-3444
Mailing Address - Fax:404-377-3445
Practice Address - Street 1:4434 JONESBORO RD
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297-4313
Practice Address - Country:US
Practice Address - Phone:404-447-3444
Practice Address - Fax:404-377-3445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-16
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty