Provider Demographics
NPI:1447208095
Name:SERC OF OVERLAND PARK KANSAS LLC
Entity Type:Organization
Organization Name:SERC OF OVERLAND PARK KANSAS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CORRADO
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:913-451-7372
Mailing Address - Street 1:7211 W 110TH ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2339
Mailing Address - Country:US
Mailing Address - Phone:913-451-7372
Mailing Address - Fax:913-451-7375
Practice Address - Street 1:7211 W 110TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66210-2339
Practice Address - Country:US
Practice Address - Phone:913-451-7372
Practice Address - Fax:913-451-7375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03366225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS34416028OtherBCBS
KS34416028OtherBCBS