MEDICARE: MRS. CATHY POERNER SUPAK ATC, LAT

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	2255A2300X	Athletic Trainer	AT-0797	TX

General Provider Information

NPI Number	:	1164570263
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CATHY POERNER SUPAK ATC, LAT

Provider Business Mailing Address
First Line	:	14714 GRAYWOOD GROVE LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77062-2108
Country	:	US
Telephone Number	:	281-480-1417
Fax Number	:	281-333-8875

Provider Business Practice Location Address
First Line	:	18100 SAINT JOHN DR
Second Line	:	SUITE 100
City	:	HOUSTON
State	:	TX
Zip	:	77058-3631
Country	:	US
Telephone Number	:	281-333-8806
Fax Number	:	281-333-8875

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	07/08/2007

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