Provider Demographics
NPI:1093920639
Name:SERC OF HARRISONVILLE, L.L.C.
Entity Type:Organization
Organization Name:SERC OF HARRISONVILLE, L.L.C.
Other - Org Name:SERC OF HARRISONVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, MANAGER, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:PURVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:816-380-3344
Mailing Address - Street 1:815 WESTCHESTER AVENUE
Mailing Address - Street 2:
Mailing Address - City:HARRISONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64701
Mailing Address - Country:US
Mailing Address - Phone:816-380-3344
Mailing Address - Fax:816-380-3044
Practice Address - Street 1:815 WESTCHESTER AVENUE
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701
Practice Address - Country:US
Practice Address - Phone:816-380-3344
Practice Address - Fax:816-380-3044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOW110000Medicare ID - Type UnspecifiedHARRISONVILLE MEDICARE