Provider Demographics
NPI:1568410165
Name:SPINE AND EXTREMITY REHABILITATION CENTER OF RAYTOWN INC
Entity Type:Organization
Organization Name:SPINE AND EXTREMITY REHABILITATION CENTER OF RAYTOWN INC
Other - Org Name:SERC OF RAYTOWN; SERC OF SOUTH RAYTOWN; SERC OF BELTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:E
Authorized Official - Last Name:NAUMANN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:816-737-5500
Mailing Address - Street 1:10801 E 350 HWY
Mailing Address - Street 2:
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64138-2367
Mailing Address - Country:US
Mailing Address - Phone:816-737-5500
Mailing Address - Fax:816-737-5504
Practice Address - Street 1:10801 E 350 HWY
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64138-2367
Practice Address - Country:US
Practice Address - Phone:816-737-5500
Practice Address - Fax:816-737-5504
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
MO2011015393225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO34362035OtherBCBS KC
MOK860000Medicare PIN
MO34362035OtherBCBS KC