Provider Demographics
NPI:1669805453
Name:ATHENS INTEGRATIVE WELLNESS CENTER
Entity type:Organization
Organization Name:ATHENS INTEGRATIVE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:903-675-8889
Mailing Address - Street 1:714 S PALESTINE ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-3325
Mailing Address - Country:US
Mailing Address - Phone:903-675-8889
Mailing Address - Fax:
Practice Address - Street 1:714 S PALESTINE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-3325
Practice Address - Country:US
Practice Address - Phone:903-675-8889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0613561363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00037NOtherMEDICARE ID-TYPE UNSPECIFIED
TXU74454Medicare UPIN