Provider Demographics
NPI:1861508541
Name:AGAVE FOOT SPECIALISTS, PLLC
Entity Type:Organization
Organization Name:AGAVE FOOT SPECIALISTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:COUCH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:623-322-5501
Mailing Address - Street 1:16841 N. 31ST AVE.
Mailing Address - Street 2:STE. 134
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-3051
Mailing Address - Country:US
Mailing Address - Phone:623-322-5501
Mailing Address - Fax:623-322-8996
Practice Address - Street 1:16841 N. 31ST AVE.
Practice Address - Street 2:STE. 134
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-3051
Practice Address - Country:US
Practice Address - Phone:623-322-5501
Practice Address - Fax:623-322-8996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0552213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZDD0997OtherRAILROAD MEDICARE
AZZ78990OtherMEDICARE ID-PIN
AZZ78990OtherMEDICARE ID-PIN