Basic Information
| Provider Information | |||||||||
| NPI: | 1952586430 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SERC OF LANSING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1004 PROGRESS DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LANSING | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660436326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133513838 | ||||||||
| FaxNumber: | 9133513939 | ||||||||
| Practice Location | |||||||||
| Address1: | 1004 PROGRESS DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LANSING | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660436326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133513838 | ||||||||
| FaxNumber: | 9133513939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2008 | ||||||||
| LastUpdateDate: | 11/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | LANGFORD | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9133513838 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MPT, ATC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11-03375 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 39845014 | 01 | KS | BCBS | OTHER |