Provider Demographics
NPI:1851496939
Name:CLINICA AGAVE CLINIC
Entity Type:Organization
Organization Name:CLINICA AGAVE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:TAKEM
Authorized Official - Last Name:CHABOT
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:678-413-2026
Mailing Address - Street 1:425 SIGMAN ROAD
Mailing Address - Street 2:SUITE #109
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012
Mailing Address - Country:US
Mailing Address - Phone:678-413-2026
Mailing Address - Fax:678-413-2030
Practice Address - Street 1:425 SIGMAN ROAD
Practice Address - Street 2:SUITE #109
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012
Practice Address - Country:US
Practice Address - Phone:678-413-2026
Practice Address - Fax:678-413-2030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty