Provider Demographics
NPI:1962450569
Name:SPINE & EXTREMITY REHABILITATION CENTER OF KANSAS CITY NORTH INC
Entity Type:Organization
Organization Name:SPINE & EXTREMITY REHABILITATION CENTER OF KANSAS CITY NORTH INC
Other - Org Name:SERC OF KANSAS CITY NORTH; SERC OF METRO NORTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:816-505-3422
Mailing Address - Street 1:220 NW PLATTE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:MO
Mailing Address - Zip Code:64150-9793
Mailing Address - Country:US
Mailing Address - Phone:816-505-3422
Mailing Address - Fax:816-505-3312
Practice Address - Street 1:220 NW PLATTE VALLEY DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:MO
Practice Address - Zip Code:64150-9793
Practice Address - Country:US
Practice Address - Phone:816-505-3422
Practice Address - Fax:816-505-3312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103074225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO27888022OtherBCBS
MOL100000Medicare PIN