Provider Demographics
NPI:1659522829
Name:SUPPLEMENTAL
Entity Type:Organization
Organization Name:SUPPLEMENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KERRI
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:SWICK
Authorized Official - Suffix:
Authorized Official - Credentials:AS
Authorized Official - Phone:816-347-5748
Mailing Address - Street 1:313B SE MELODY LN
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64063-2915
Mailing Address - Country:US
Mailing Address - Phone:816-682-7197
Mailing Address - Fax:816-347-5798
Practice Address - Street 1:20 NE SAINT LUKES BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-6001
Practice Address - Country:US
Practice Address - Phone:816-347-5748
Practice Address - Fax:816-347-5798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007023014273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit