Clinica Agave Clinic

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

Legal business name

CLINICA AGAVE CLINIC

Practice address

425 Sigman Road
Suite #109
Conyers, GA 30012

Phone

(678) 413-2026

Fax

(678) 413-2030

NPI assigned

Sep 14, 2006

Last updated

Mar 23, 2010By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Judith Takem Chabot, FNP-CNPI 1063419216

Title

Owner/Administrator

Phone

(678) 413-2026

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 Nurse Practitioner
  • Forest Park, GA
  • NPI 1407091705
  NPD tax ID

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Judith T Chabot, FNP-C

  • Family Nurse Practitioner
  • Conyers, GA
  • NPI 1063419216
  NPD (past) Authorized official

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

{
    "created_epoch": "1158192000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1269302400000",
    "number": "1851496939",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "425 SIGMAN ROAD",
            "address_2": "SUITE #109",
            "city": "CONYERS",
            "state": "GA",
            "postal_code": "30012",
            "telephone_number": "678-413-2026",
            "fax_number": "678-413-2030"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "425 SIGMAN ROAD",
            "address_2": "SUITE #109",
            "city": "CONYERS",
            "state": "GA",
            "postal_code": "30012",
            "telephone_number": "678-413-2026",
            "fax_number": "678-413-2030"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLINICA AGAVE CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-14",
        "last_updated": "2010-03-23",
        "status": "A",
        "authorized_official_last_name": "CHABOT",
        "authorized_official_first_name": "JUDITH",
        "authorized_official_middle_name": "TAKEM",
        "authorized_official_title_or_position": "OWNER/ADMINISTRATOR",
        "authorized_official_telephone_number": "678-413-2026",
        "authorized_official_credential": "FNP-C"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Camille Clarke, LPN
• Janice A Clarke, MD
• Shawnta Dione Clarke, LPC
• Clear Speech, LLC
• Diana Cleveland, IBCLC, RN
• Closer to Eden Inc
• Derrell Coakley Sr.
• Angela C Coates, CSA
• Brandy Elisher Coffee, RD LD
• Chris J Coffini, OD

• Family Medicine Physician in Conyers, GA
• Providers in Conyers, GA by specialty
• Family Medicine Physician in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 23, 2010; 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.