Provider Demographics
NPI:1578677415
Name:ATHENA HEALTH CENTER, LLC
Entity Type:Organization
Organization Name:ATHENA HEALTH CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:L
Authorized Official - Last Name:LAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-422-5600
Mailing Address - Street 1:1601 GRAND CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-1082
Mailing Address - Country:US
Mailing Address - Phone:304-422-5600
Mailing Address - Fax:304-422-5993
Practice Address - Street 1:1601 GRAND CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-1082
Practice Address - Country:US
Practice Address - Phone:304-422-5600
Practice Address - Fax:304-422-5993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1578677415Medicaid