Provider Demographics
NPI:1467051185
Name:AGAPE MEDICAL GROUP
Entity Type:Organization
Organization Name:AGAPE MEDICAL GROUP
Other - Org Name:WILDFIRE WEIGHT LOSS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:
Authorized Official - First Name:AUTEUM
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:207-951-0423
Mailing Address - Street 1:203 MANN HILL RD
Mailing Address - Street 2:
Mailing Address - City:HOLDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04429-6230
Mailing Address - Country:US
Mailing Address - Phone:207-951-0423
Mailing Address - Fax:
Practice Address - Street 1:46 BETTON ST STE 204
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-2636
Practice Address - Country:US
Practice Address - Phone:207-951-0423
Practice Address - Fax:207-544-5107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-23
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service