Basic Information
| Provider Information | |||||||||
| NPI: | 1760817472 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SERC REHABILITATION PARTNERS, LLC | ||||||||
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| OtherOrganizationName: | SERC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17134 BEL RAY PL | ||||||||
| Address2: | |||||||||
| City: | BELTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640125331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163180436 | ||||||||
| FaxNumber: | 8163180437 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 W 92 HWY STE H | ||||||||
| Address2: | |||||||||
| City: | KEARNEY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640607591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8169030775 | ||||||||
| FaxNumber: | 8169030776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2013 | ||||||||
| LastUpdateDate: | 10/09/2017 | ||||||||
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| AuthorizedOfficialLastName: | JOHANNESON | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP REVENUE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4232388923 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.