Provider Demographics
NPI:1588229801
Name:SUPERABLE, ANGEL JR (PT)
Entity Type:Individual
Prefix:MR
First Name:ANGEL
Middle Name:
Last Name:SUPERABLE
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77414-3920
Mailing Address - Country:US
Mailing Address - Phone:979-245-6327
Mailing Address - Fax:979-245-0164
Practice Address - Street 1:1800 13TH ST
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:TX
Practice Address - Zip Code:77414-3920
Practice Address - Country:US
Practice Address - Phone:979-245-6327
Practice Address - Fax:979-245-0164
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1082089225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist