Provider Demographics
NPI:1013225002
Name:SANANIKONE, SOURACHACK STEVE (DPT)
Entity Type:Individual
Prefix:
First Name:SOURACHACK
Middle Name:STEVE
Last Name:SANANIKONE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13202 BRIAR FOREST DR
Mailing Address - Street 2:APT. # 1108
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-2434
Mailing Address - Country:US
Mailing Address - Phone:443-235-6410
Mailing Address - Fax:
Practice Address - Street 1:5151 KATY FWY
Practice Address - Street 2:SUITE 305
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77007-2260
Practice Address - Country:US
Practice Address - Phone:713-562-1031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-23
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1200953225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist