Provider Demographics
NPI:1063191138
Name:BLUE AGAVE FUNCTIONAL MEDICINE CLINIC PLLC
Entity type:Organization
Organization Name:BLUE AGAVE FUNCTIONAL MEDICINE CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:KNEPPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-293-9800
Mailing Address - Street 1:3221 COMMERCIAL CIR
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78132-4447
Mailing Address - Country:US
Mailing Address - Phone:830-491-4040
Mailing Address - Fax:830-402-2171
Practice Address - Street 1:3221 COMMERCIAL CIR
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78132-4447
Practice Address - Country:US
Practice Address - Phone:830-491-4040
Practice Address - Fax:830-402-2171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-14
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty