Provider Demographics
NPI:1407901879
Name:ATHENA BREAST CARE CENTER LLC
Entity Type:Organization
Organization Name:ATHENA BREAST CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:KLING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-581-8500
Mailing Address - Street 1:110 MARTER AVE
Mailing Address - Street 2:BUILDING 500 SUITE 506
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-3124
Mailing Address - Country:US
Mailing Address - Phone:856-581-8500
Mailing Address - Fax:856-581-8503
Practice Address - Street 1:110 MARTER AVE
Practice Address - Street 2:BUILDING 500 SUITE 506
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-3124
Practice Address - Country:US
Practice Address - Phone:856-581-8500
Practice Address - Fax:856-581-8503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05730600208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ110178Medicare PIN