Basic Information
| Provider Information | |||||||||
| NPI: | 1912956079 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SERC HAND REHABILITATION SOUTH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7211 W 110TH ST | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662102339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9134517372 | ||||||||
| FaxNumber: | 9134517375 | ||||||||
| Practice Location | |||||||||
| Address1: | 7211 W 110TH ST | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662102339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9134517372 | ||||||||
| FaxNumber: | 9134517375 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 11/02/2012 | ||||||||
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| AuthorizedOfficialLastName: | REED | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9134517372 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OTR/L, CHT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | 17-00153 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
ID Information
| ID | Type | State | Issuer | Description | 34418024 | 01 | KS | BCBS | OTHER |