Provider Demographics
NPI:1417229972
Name:SUPPLEMENTAL HEALTH CARE
Entity Type:Organization
Organization Name:SUPPLEMENTAL HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PTA
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-236-1553
Mailing Address - Street 1:6628 RICHARDSON DR
Mailing Address - Street 2:
Mailing Address - City:WATAUGA
Mailing Address - State:TX
Mailing Address - Zip Code:76148-2335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5601 BRIDGE ST
Practice Address - Street 2:SUITE 490
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-2384
Practice Address - Country:US
Practice Address - Phone:877-441-7800
Practice Address - Fax:877-441-7802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital