Provider Demographics
NPI:1992980239
Name:AGAVE MEDICAL CENTER, LLC
Entity type:Organization
Organization Name:AGAVE MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:ROONEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-425-3557
Mailing Address - Street 1:703 E ASH ST
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:GLOBE
Mailing Address - State:AZ
Mailing Address - Zip Code:85501-1865
Mailing Address - Country:US
Mailing Address - Phone:928-425-3557
Mailing Address - Fax:
Practice Address - Street 1:703 E ASH ST
Practice Address - Street 2:SUITE 1B
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-1865
Practice Address - Country:US
Practice Address - Phone:928-425-3557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-06
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ28273261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care