NPI |
1922107325 |
The abbreviations for professional degrees or credentials used or held by the provider,
if the provider is an individual. Examples
are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations
will not be verified by NPS. |
Entity Type Code |
2 |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
Employer Identification Number EIN |
|
The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot
include a Post Office box. |
Provider Organization Name Legal Business Name |
STATE COMMUNITY REHAB AGENCY, INC. |
The city name in the location address of the provider being identified. |
Provider First Line Business Practice Location Address |
11205 MAIN ST STE 118 |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address City Name |
HOUSTON |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Provider Business Practice Location Address State Name |
TX |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Postal Code |
770255602 |
The telephone number associated with the location address of the provider being identified. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The fax number associated with the location
address of the provider being identified. |
Provider Business Practice Location Address Telephone Number |
7136620501 |
The telephone number associated with the location address of the provider being identified. |
Provider Enumeration Date |
9/22/2006 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Last Update Date |
8/22/2020 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Authorized Official Last Name |
MICKENS |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
Authorized Official First Name |
CAROLYN |
The first name of the authorized official. |
Authorized Official Title or Position |
COORDINATOR |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Authorized Official Telephone Number |
7136620502 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Healthcare Provider Taxonomy Code 1 |
273Y00000X |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Is Organization Subpart |
N |
|
Authorized Official Name Prefix Text |
MRS. |
|