Provider Demographics
NPI:1487704540
Name:ATHENA COMPLETE CARE LLC
Entity type:Organization
Organization Name:ATHENA COMPLETE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:BAILEY
Authorized Official - Last Name:POOL
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:256-262-4970
Mailing Address - Street 1:PO BOX 66
Mailing Address - Street 2:
Mailing Address - City:TANNER
Mailing Address - State:AL
Mailing Address - Zip Code:35671-0066
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:727 W MARKET ST
Practice Address - Street 2:SUITE 5
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35611-2456
Practice Address - Country:US
Practice Address - Phone:256-262-4970
Practice Address - Fax:256-262-4971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-087387363LA2100X
AL18295207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALF84057Medicare UPIN