Provider Demographics
NPI:1326612193
Name:ATHENA MEDICAL GROUP OF THE CENTRAL COAST, INC.
Entity Type:Organization
Organization Name:ATHENA MEDICAL GROUP OF THE CENTRAL COAST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KHIEU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-665-6084
Mailing Address - Street 1:PO BOX 10627
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93912-7627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 ALAMEDA AVE STE A
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-4024
Practice Address - Country:US
Practice Address - Phone:831-900-5113
Practice Address - Fax:831-900-5113
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATHENA MEDICAL GROUP OF THE CENTRAL COAST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental