Provider Demographics
NPI:1699001164
Name:SERC OF ODESSA INC
Entity Type:Organization
Organization Name:SERC OF ODESSA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR/AREA DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:DOWDY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:816-633-4063
Mailing Address - Street 1:211 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:MO
Mailing Address - Zip Code:64076-1135
Mailing Address - Country:US
Mailing Address - Phone:816-633-4063
Mailing Address - Fax:816-633-4264
Practice Address - Street 1:211 N 2ND ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:MO
Practice Address - Zip Code:64076-1135
Practice Address - Country:US
Practice Address - Phone:816-633-4063
Practice Address - Fax:816-633-4264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-19
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20020068342251H1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO34362045OtherBCBS
MOMA2104Medicare PIN