Provider Demographics
NPI:1740915008
Name:AGILE OCCUPATIONAL MEDICINE, PC
Entity type:Organization
Organization Name:AGILE OCCUPATIONAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:844-207-8321
Mailing Address - Street 1:3200 BRISTOL ST STE 600
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-1810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:445 E ANAHEIM ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-4600
Practice Address - Country:US
Practice Address - Phone:562-267-3798
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AGILE OCCUPATIONAL MEDICINE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy