Provider Demographics
NPI:1851869234
Name:BLUE AGAVE WOUND CARE SOLUTIONS LLC
Entity Type:Organization
Organization Name:BLUE AGAVE WOUND CARE SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER LLC
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:CARNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-568-6800
Mailing Address - Street 1:PO BOX 170434
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-0027
Mailing Address - Country:US
Mailing Address - Phone:844-275-3822
Mailing Address - Fax:
Practice Address - Street 1:10109 LAKE CREEK PKWY UNIT 170434
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78717-0119
Practice Address - Country:US
Practice Address - Phone:844-275-3822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Multi-Specialty
No163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No364SH0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHome HealthGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty