=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861889263
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUPERIOR HEALTHCARE PHYSICAL MEDICINE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2015
-----------------------------------------------------
Last Update Date | 05/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24124 CINCO VILLAGE CENTER BLVD SUITE 300
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77494-8396
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-547-5539
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24124 CINCO VILLAGE CENTER BLVD SUITE 300
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77494-8396
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-547-5539
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAVID DALE ELLIS
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 281-574-5539
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------