Basic Information
| Provider Information | |||||||||
| NPI: | 1427007566 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SERC OF LIBERTY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1512 NE 96TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640681348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167920775 | ||||||||
| FaxNumber: | 8167920776 | ||||||||
| Practice Location | |||||||||
| Address1: | 1512 NE 96TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640681348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167920775 | ||||||||
| FaxNumber: | 8167920776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 11/02/2012 | ||||||||
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| AuthorizedOfficialLastName: | HELMER | ||||||||
| AuthorizedOfficialFirstName: | CHAD | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8167920775 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 112594 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 31732022 | 01 | MO | BCBS | OTHER |