Provider Demographics
NPI:1215355243
Name:SERC REHABILITATION PARTNERS LLC
Entity Type:Organization
Organization Name:SERC REHABILITATION PARTNERS LLC
Other - Org Name:SERC - SAINT JOSEPH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR OF PROVIDER/PAYER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:KILEY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-238-8923
Mailing Address - Street 1:17134 BEL RAY PL
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:MO
Mailing Address - Zip Code:64012-5331
Mailing Address - Country:US
Mailing Address - Phone:816-226-4011
Mailing Address - Fax:816-524-6115
Practice Address - Street 1:3727 GENE FIELD RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-1806
Practice Address - Country:US
Practice Address - Phone:816-396-8635
Practice Address - Fax:816-364-3522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-07
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA4370OtherGROUP MEDICARE PTAN