1063191138 NPI number — BLUE AGAVE FUNCTIONAL MEDICINE CLINIC PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063191138 NPI number — BLUE AGAVE FUNCTIONAL MEDICINE CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLUE AGAVE FUNCTIONAL MEDICINE CLINIC PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063191138
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3221 COMMERCIAL CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW BRAUNFELS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78132-4447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-491-4040
Provider Business Mailing Address Fax Number:
830-402-2171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3221 COMMERCIAL CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW BRAUNFELS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78132-4447
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-491-4040
Provider Business Practice Location Address Fax Number:
830-402-2171
Provider Enumeration Date:
07/14/2023

Additional Information

Authorized Official

Authorized Official Last Name:
KNEPPER
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
512-293-9800

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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