Provider Demographics
NPI:1760102644
Name:ATHENA MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:ATHENA MEDICAL CLINIC LLC
Other - Org Name:ATHENA MEDICAL CLINIC LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:IOLANI MAE
Authorized Official - Middle Name:SY
Authorized Official - Last Name:AVES
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:713-584-9013
Mailing Address - Street 1:30575 KINGSLAND BLVD # 150
Mailing Address - Street 2:
Mailing Address - City:BROOKSHIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77423-2844
Mailing Address - Country:US
Mailing Address - Phone:281-717-4674
Mailing Address - Fax:833-318-0533
Practice Address - Street 1:30575 KINGSLAND BLVD # 150
Practice Address - Street 2:
Practice Address - City:BROOKSHIRE
Practice Address - State:TX
Practice Address - Zip Code:77423-2844
Practice Address - Country:US
Practice Address - Phone:281-717-4674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-31
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty