Basic Information
| Provider Information | |||||||||
| NPI: | 1699001164 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SERC OF ODESSA INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 211 N 2ND ST | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640761135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166334063 | ||||||||
| FaxNumber: | 8166334264 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 N 2ND ST | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640761135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8166334063 | ||||||||
| FaxNumber: | 8166334264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2009 | ||||||||
| LastUpdateDate: | 11/02/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DOWDY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC DIRECTOR/AREA DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8166334063 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251H1200X | 2002006834 | MO | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand |
ID Information
| ID | Type | State | Issuer | Description | 34362045 | 01 | MO | BCBS | OTHER |