MEDICARE: ATHENA LEASING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	4604	TX

General Provider Information

NPI Number	:	1790839579
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATHENA LEASING LLC

Provider Business Mailing Address
First Line	:	1001 CROSS TIMBERS RD
Second Line	:	SUITE 2275
City	:	FLOWER MOUND
State	:	TX
Zip	:	75028-1371
Country	:	US
Telephone Number	:	972-355-4957
Fax Number	:

Provider Business Practice Location Address
First Line	:	2611 W 46TH AVE
Second Line	:
City	:	AMARILLO
State	:	TX
Zip	:	79110-1735
Country	:	US
Telephone Number	:	806-355-6517
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. GERRY FOWLER
Credential	:
Telephone Number	:	972-355-4957

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	08/22/2020

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