Healthcare Provider Details

I. General information

NPI: 1487704540
Provider Name (Legal Business Name): ATHENA COMPLETE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

727 W MARKET ST SUITE 5
ATHENS AL
35611-2456
US

IV. Provider business mailing address

PO BOX 66
TANNER AL
35671-0066
US

V. Phone/Fax

Practice location:
  • Phone: 256-262-4970
  • Fax: 256-262-4971
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18295
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1-087387
License Number StateAL

VIII. Authorized Official

Name: MRS. ASHLEY BAILEY POOL
Title or Position: OWNER
Credential: CRNP
Phone: 256-262-4970