Basic Information
| Provider Information | |||||||||
| NPI: | 1073706362 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ATHENA LEASING, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DIMMITT NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 CROSS TIMBERS RD | ||||||||
| Address2: | SUITE 1060 | ||||||||
| City: | FLOWER MOUND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750281371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723554957 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1621 BUTLER DR | ||||||||
| Address2: | |||||||||
| City: | DIMMITT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 790272701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8066473117 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2007 | ||||||||
| LastUpdateDate: | 08/21/2007 | ||||||||
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| AuthorizedOfficialLastName: | FOWLER | ||||||||
| AuthorizedOfficialFirstName: | GERRY | ||||||||
| AuthorizedOfficialMiddleName: | DWAIN | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9723554957 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 4948 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.