Clinica Agave Clinic

Primary specialty

Family Nurse PractitionerTaxonomy code 363LF0000X

Legal business name

CLINICA AGAVE CLINIC

Practice address

4434 Jonesboro Rd
Forest Park, GA 30297-4313

Phone

(404) 447-3444

Fax

(404) 377-3445

NPI assigned

Dec 16, 2008

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Judith T Chabot, FNP-C

Title

Provider

Phone

(404) 447-3444

Specialties & licenses 1

Addresses

Tax ID family

Clinica Agave Clinic2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Clinica Agave Clinic

  • Family Medicine Physician
  • Conyers, GA
  • NPI 1851496939
  NPD tax ID

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1229385600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1229385600000",
    "number": "1407091705",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4434 JONESBORO RD",
            "city": "FOREST PARK",
            "state": "GA",
            "postal_code": "302974313",
            "telephone_number": "404-447-3444",
            "fax_number": "404-377-3445"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4434 JONESBORO RD",
            "city": "FOREST PARK",
            "state": "GA",
            "postal_code": "302974313",
            "telephone_number": "404-447-3444",
            "fax_number": "404-377-3445"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLINICA AGAVE CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-12-16",
        "last_updated": "2008-12-16",
        "status": "A",
        "authorized_official_last_name": "CHABOT",
        "authorized_official_first_name": "JUDITH",
        "authorized_official_middle_name": "T",
        "authorized_official_title_or_position": "PROVIDER",
        "authorized_official_telephone_number": "404-447-3444",
        "authorized_official_credential": "FNP-C"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Family Nurse Practitioner in Forest Park, GA
• Providers in Forest Park, GA by specialty
• Family Nurse Practitioner in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 16, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.