Basic Information
Provider Information
NPI: 1306053632
EntityType: 2
ReplacementNPI:  
OrganizationName: SERC OF LEE'S SUMMIT
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3500 SW MARKET ST
Address2:  
City: LEES SUMMIT
State: MO
PostalCode: 640822327
CountryCode: US
TelephoneNumber: 8165375650
FaxNumber: 8165375649
Practice Location
Address1: 3500 SW MARKET ST
Address2:  
City: LEES SUMMIT
State: MO
PostalCode: 640822327
CountryCode: US
TelephoneNumber: 8165375650
FaxNumber: 8165375649
Other Information
ProviderEnumerationDate: 05/17/2007
LastUpdateDate: 08/22/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: WERNSMAN
AuthorizedOfficialFirstName: MARK
AuthorizedOfficialMiddleName: A
AuthorizedOfficialTitleorPosition: OWNER, MANAGER, PHYSICAL THERAPIST
AuthorizedOfficialTelephone: 8165375650
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MPT
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
332BC3200X MOY SuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment

No ID Information.


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