Healthcare Provider Details

I. General information

NPI: 1992313472
Provider Name (Legal Business Name): ATHENA MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2020
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 W 17TH ST
RIVIERA BEACH FL
33404-6121
US

IV. Provider business mailing address

9050 PINES BLVD STE 460
PEMBROKE PINES FL
33024-6402
US

V. Phone/Fax

Practice location:
  • Phone: 954-314-8202
  • Fax: 954-842-4347
Mailing address:
  • Phone: 954-314-8202
  • Fax: 954-842-4347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRYAN ALZATE
Title or Position: CEO
Credential:
Phone: 954-314-8202