Basic Information
| Provider Information | |||||||||
| NPI: | 1215355243 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SERC REHABILITATION PARTNERS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SERC - SAINT JOSEPH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17134 BEL RAY PL | ||||||||
| Address2: | |||||||||
| City: | BELTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640125331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162264011 | ||||||||
| FaxNumber: | 8165246115 | ||||||||
| Practice Location | |||||||||
| Address1: | 3727 GENE FIELD RD | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645061806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163968635 | ||||||||
| FaxNumber: | 8163643522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2014 | ||||||||
| LastUpdateDate: | 04/07/2014 | ||||||||
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| AuthorizedOfficialLastName: | RUSSELL | ||||||||
| AuthorizedOfficialFirstName: | KILEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MGR OF PROVIDER/PAYER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 4232388923 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | MA4370 | 01 | MO | GROUP MEDICARE PTAN | OTHER |