Basic Information
| Provider Information | |||||||||
| NPI: | 1093920639 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SERC OF HARRISONVILLE, L.L.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SERC OF HARRISONVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 815 WESTCHESTER AVENUE | ||||||||
| Address2: | |||||||||
| City: | HARRISONVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163803344 | ||||||||
| FaxNumber: | 8163803044 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 WESTCHESTER AVENUE | ||||||||
| Address2: | |||||||||
| City: | HARRISONVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163803344 | ||||||||
| FaxNumber: | 8163803044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PURVIS | ||||||||
| AuthorizedOfficialFirstName: | SHERRY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER, MANAGER, PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 8163803344 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | MO | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
No ID Information.