Provider Demographics
NPI:1376837922
Name:SUPPLEMENTAL HEALTHCARE
Entity Type:Organization
Organization Name:SUPPLEMENTAL HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:TERESA
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:832-878-1522
Mailing Address - Street 1:4620 N BRAESWOOD BLVD APT 52
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77096-2847
Mailing Address - Country:US
Mailing Address - Phone:832-878-1522
Mailing Address - Fax:832-516-8063
Practice Address - Street 1:4620 N BRAESWOOD BLVD APT 52
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77096-2847
Practice Address - Country:US
Practice Address - Phone:832-878-1522
Practice Address - Fax:832-516-8063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-31
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management