Provider Demographics
NPI:1396284295
Name:STATERA PHYSICAL THERAPY AND REHABILITATION CLINIC, PLLC
Entity type:Organization
Organization Name:STATERA PHYSICAL THERAPY AND REHABILITATION CLINIC, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDEN
Authorized Official - Middle Name:YOUNMYUNG
Authorized Official - Last Name:KANG
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:346-802-3188
Mailing Address - Street 1:13711 WESTHEIMER RD # J-A
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-5304
Mailing Address - Country:US
Mailing Address - Phone:281-493-4718
Mailing Address - Fax:832-827-4345
Practice Address - Street 1:8830 LONG POINT RD STE 206
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77055-3018
Practice Address - Country:US
Practice Address - Phone:346-802-3188
Practice Address - Fax:346-802-3187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-13
Last Update Date:2024-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1269878261QP2000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX370821601Medicaid