Provider Demographics
NPI:1831234939
Name:ATHENA DIAGNOSTICS, INC.
Entity type:Organization
Organization Name:ATHENA DIAGNOSTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KARTHIK
Authorized Official - Middle Name:
Authorized Official - Last Name:KUPPUSAMY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-756-2886
Mailing Address - Street 1:200 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:MARLBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01752
Mailing Address - Country:US
Mailing Address - Phone:508-756-2886
Mailing Address - Fax:508-753-5601
Practice Address - Street 1:200 FOREST ST
Practice Address - Street 2:
Practice Address - City:MARLBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01752
Practice Address - Country:US
Practice Address - Phone:508-756-2886
Practice Address - Fax:508-753-5601
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:QUEST DIAGNOSTICS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-20
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2418291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA228388Medicare ID - Type Unspecified
MA22D0069726Medicare UPIN