Provider Demographics
NPI:1265165484
Name:AGAVE FAMILY MEDICINE & BREAST FEEDING SUPPORT CENTER LLC
Entity type:Organization
Organization Name:AGAVE FAMILY MEDICINE & BREAST FEEDING SUPPORT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:HARREL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-999-4659
Mailing Address - Street 1:1925 W ORANGE GROVE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-1151
Mailing Address - Country:US
Mailing Address - Phone:520-372-2167
Mailing Address - Fax:
Practice Address - Street 1:1925 W ORANGE GROVE RD STE 201
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-1151
Practice Address - Country:US
Practice Address - Phone:520-372-2167
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-06
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty