MEDICARE: STATE COMMUNITY REHAB AGENCY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	273Y00000X	Rehabilitation Hospital Unit

General Provider Information

NPI Number	:	1922107325
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE COMMUNITY REHAB AGENCY, INC.

Provider Business Mailing Address
First Line	:	11205 MAIN ST STE 118
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77025-5602
Country	:	US
Telephone Number	:	713-662-0501
Fax Number	:

Provider Business Practice Location Address
First Line	:	11205 MAIN ST STE 118
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77025-5602
Country	:	US
Telephone Number	:	713-662-0501
Fax Number	:

Authorized Official
Title or Position	:	COORDINATOR
Name	:	MRS. CAROLYN MICKENS
Credential	:
Telephone Number	:	713-662-0502

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	08/22/2020

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