Healthcare Provider Details

I. General information

NPI: 1790839579
Provider Name (Legal Business Name): ATHENA LEASING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 W 46TH AVE
AMARILLO TX
79110-1735
US

IV. Provider business mailing address

1001 CROSS TIMBERS RD SUITE 2275
FLOWER MOUND TX
75028-1371
US

V. Phone/Fax

Practice location:
  • Phone: 806-355-6517
  • Fax:
Mailing address:
  • Phone: 972-355-4957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number4604
License Number StateTX

VIII. Authorized Official

Name: MR. GERRY FOWLER
Title or Position: PRESIDENT
Credential:
Phone: 972-355-4957