Basic Information
| Provider Information | |||||||||
| NPI: | 1871724047 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SERC HAND OF CASS COUNTY LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SERC HAND HARRISONVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 815 WESTCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | HARRISONVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647011784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163803344 | ||||||||
| FaxNumber: | 8153803044 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 WESTCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | HARRISONVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647011784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163803344 | ||||||||
| FaxNumber: | 8153803044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2009 | ||||||||
| LastUpdateDate: | 08/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | HARNDEN | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8163803344 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OTR/L, CHT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | 2006025819 | MO | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
ID Information
| ID | Type | State | Issuer | Description | 38514011 | 01 | MO | BCBS OF KC | OTHER |