Provider Demographics
NPI:1336869544
Name:STATERA RESTON LLC
Entity Type:Organization
Organization Name:STATERA RESTON LLC
Other - Org Name:FYZICAL THERAPY AND BALANCE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEPPERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-409-3483
Mailing Address - Street 1:42020 VILLAGE CENTER PLZ STE 120
Mailing Address - Street 2:PMB 1046
Mailing Address - City:STONE RIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:20105-3030
Mailing Address - Country:US
Mailing Address - Phone:713-409-3483
Mailing Address - Fax:
Practice Address - Street 1:11410 RESTON STATION BLVD
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5363
Practice Address - Country:US
Practice Address - Phone:713-409-3483
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-29
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty